NC-Withholding Form

This field is for validation purposes and should be left unchanged.

Filing Status

Single or Married Filing Separately

Head of Household

Married Filing Jointly or Surviving Spouse

Social Security Number

First Name

M.I

Last Name

Address

County (Entry first five letters)

City

State

Zip

County (if not U.S)

1. Total number of allowances you are claiming (Enter zero (0), or the number of allowances from the table above)

2. Additional amount, if any, you want withheld from each pay period (Enter whole dollars)

Last year, I was entitled to a refund of all State income tax withheld because I had no tax liability; This year, I expect a refund of all State income tax withheld because I expect to have no tax liability.

3. I certify that I am exempt from North Carolina withholding because I meet both of the following conditions:

Last year, I was entitled to a refund of all State income tax withheld because I had no tax liability;

This year, I expect a refund of all State income tax withheld because I expect to have no tax liability.

(For more information, see Form D-401, North Carolina Individual Income Tax Instructions.)

4. I certify that I am exempt from North Carolina withholding because I meet the requirements set forth in the Servicemembers Civil Relief Act. (For more information, see Form D-401, North Carolina Individual Income Tax Instructions.)

(For more information, see Form D-401, North Carolina Individual Income Tax Instructions.)

(for more information, see Form D-401, North Carolina Individual Income Tax Instructions.)

5. I certify that I am exempt from North Carolina withholding because I am an enrolled member of a federally recognized Indian tribe and meet the requirements set forth in G.S. 105-153.5(b)(6).

(for more information, see Form D-401, North Carolina Individual Income Tax Instructions.)

If you selected an exemption on Lines 3, 4, or 5 above, enter the year the exemption became effective

6. I certify that I no longer meet the requirements for an exemption on:

Line 3

Line 4

Line 5

Therefore, I revoke my exemption and request that my employer withhold North Carolina income tax based on the Check Here tr number of allowances entered on Line 1 and any additional amount entered on Line 2.

Employee's Signature

Date

MM slash DD slash YYYY

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