Check all that apply
No one else can claim me as a dependent.
I can claim my spouse as a dependent.
1. Enter the total number of boxes you checked.
2. Enter the number of dependents (other than you or your spouse) you will claim on your tax return.
3. Add Lines 1 and 2. Enter the result. This is the total number of basic personal allowances to which you are entitled. You are not required to claim these allowances. The number of basic personal allowances that you choose to claim will determine how much money is withheld from your pay. See Line 4 for more information.
4. Enter the total number of basic personal allowances you choose to claim on this line and Line 1 of Form IL W 4 below. This number may not exceed the amount on Line 3 above, however you can claim as few as zero. Entering lower numbers here will result in more money being withheld (deducted) from your pay.
Check all that apply
I am 65 or older.
I am legally blind.
My spouse is 65 or older.
My spouse is legally blind.
5. Enter the total number of boxes you checked.
6. Enter any amount that you reported on Line 4 of the Deductions Worksheet for federal Form W 4 plus any additional Illinois subtractions or deductions.
7. Divide Line 6 by 1,000. Round to the nearest whole number. Enter the result on Line 7
8. Add Lines 5 and 7. Enter the result. This is the total number of additional allowances to which you are entitled. You are not required to claim these allowances. The number of additional allowances that you choose to claim will determine how much money is withheld from your pay.
9. Enter the total number of additional allowances you elect to claim on Line 2 of Form IL W 4, below. This number may not exceed the amount on Line 8 above, however you can claim as few as zero. Entering lower numbers here will result in more money being withheld (deducted) from your pay.
Social Security Number (SSN)
Name
Address
Street Address
Apt
City
State / Province
Postal / Zip Code
Check the box if you are exempt from federal and IllinoisIncome Tax withholding and sign and date the certificate.
1. Enter the total number of basic allowances that you are claiming (Step 1, Line 4, of the worksheet).
2. Enter the total number of additional allowances that you are claiming (Step 2, Line 9, of the worksheet).
3 Enter the additional amount you want withheld (deducted) from each pay. 3
I certify that I am entitled to the number of withholding allowances claimed on this certificate.
Date
/
Month
/
Day
Year
Date
Your signature
Preview PDF
Submit
Should be Empty: