Substitute Form Of W 4 – Fill Out and Use This PDF

Substitute form in lieu of IRS Form W-4 (Rev. 01-05)

Page 2

completed IRS Form W-4 withholding

to any internal revenue tax.(See §7701(a)(14))

Request for TIN/ Reporting to the I.R.S.

allowance certificate.

26 CFR §301.6109-1(c) requires you, the

Those United States citizens and individuals

Withholding Allowance Certificate

payer, only to request disclosure of one’s Tax

whose income does not originate under any of

A “withholding allowance certificate” [IRS Form

Identification Number. When the person

the three situations listed may provide the

W-4] is a form individuals may voluntarily use

refuses, the law requires you to ask a second

employer with a withholding exemption

to certify to the employer that the individual is

time while stating only the request for

certificate in lieu of Form W-4.

a U.S. citizen liable for U.S. income tax and

disclosure is required by law. When the

American Citizens may certify that they are

allows the employer to act as the individual’s

person refuses a second time, you are

not subject to the U.S. income tax by providing

withholding agent.

required to prepare an affidavit (signed by you

a statement of citizenship in lieu of Form W-4.

Note: It is illegal for an employer to withhold

and individual) stating you have complied with

Neither the U.S. Department of the Treasury

tax from a payment to an employee if the

the request, keeping the affidavit as a

nor the Internal Revenue Service provides

employee does not voluntarily furnish the

permanent record in the file you maintain on

“officially printed” withholding exemption

employer with a singed withholding allowance

the person.

certificates or statements of citizenship. It is

certificate.

Leave the box for the individual’s SSN or TIN

entirely up to the individual who is not subject

blank when making all necessary reports.

to or liable for the U.S. income tax to provide

Withholding Exemption Certificate

Note: This is the correct procedure when the

such documents.

A “withholding exemption certificate” is a form

individual does not have or refuses to disclose

individuals may voluntarily use to certify to an

a Social Security Number regardless of which

Definitions:

employer that the individual is not liable for

form is being used.

American Citizen

U.S. income tax and exempts the employer

Employers are required by law to be in

For purposes of this form, “American Citizen”

from any U.S. income tax withholding rules.

accordance with the ruling of EQUAL

(See §3402(f)(2))

EMPLOYMENT OPPORTUNITY COMMISION

and “Citizen of the united States of America”

The employer is not required to deduct

v. INFORMATION SYSTEMS CONSULTING,

means an individual who was born or

and withhold any tax upon a payment of

United States District Court for the Northern

naturalized in any of the 50 States of

wages to an employee if this form or substitute

District of Texas Dallas Division CA3-92-0169-

America.

is filed in lieu of Form W-4.

T, which states, “the defendant shall be

Note: You are an individual not subject to

Note: A withholding exemption certificate

permanently enjoined from terminating an

income tax if you are an American Citizen

should state that (a) the employee incurred no

employee or refusing to hire an individual for

residing within the united States of America

liability for income tax imposed under subtitle

failure to provide a social security number.”

(the 50 states).

A of the Code for his preceding taxable year;

American Citizens cannot be compelled to

and (b) the employee anticipates that he will

Disposition of Statement and Form

register in and subsequently participate in

incur no liability for income tax imposed by

Upon receiving this form send a copy along

government entitlement programs, as the

subtitle A for his current taxable year.

with a letter of transmittal to: Internal Revenue

authority to require such is a power which

Center, Philadelphia, PA 19255. (See CFR

“obviously lie(s) outside the orbit of

Statement of Citizenship

§1.1441-5 Claiming to be a person not subject

congressional power”. Railroad Retirement

Board v. Alton Railroad Co. 295 U.S. 330, 55

An individual’s written statement that he or she

to withholding)

Ct. 758 (1935).

is an American Citizen may also be relied

Transmittal Letter

upon by the payer of the income as proof that

United States

such individual is a citizen or resident of the

Your transmittal letter should state that you

For income tax purposes, “United States”

united States of America and therefore not

requested the individual’s SSN as instructed

subject to the U.S. income tax. (See CFR

by §6109(a)(3) and/or 26 CFR

means District of Columbia, the

§1.1441-5 Claiming to be a person not subject

§301.6109-1(c) and that you are asserting

Commonwealth of Puerto Rico, the Virgin

to withholding)

§6724(a) or 26 CFR §301.6676-1(a) for your

Islands, Guam, and American Samoa. (See

waiver of any penalties that may be associated

§3121(e), §7701(a)(9), and 42 USC §410(i))

with your justifiable failure that is due to

Specific Instructions:

U.S. citizen

Worker

reasonable cause:

1) To withhold tax from payments to the

For income tax purposes, “U.S. citizen” and

Full Name: Enter your last name followed by

individual, and

“United States citizen” means an individual

your first name and then your middle name or

2) To use a Social Security Number in making

who is a citizen of District of Columbia, the

initial.

reports to the I.R.S. regarding the individual.

Commonwealth of Puerto Rico, the Virgin

Postal Location: Enter your address where

Note: It is reasonable cause if the employee

Islands, Guam, and American Samoa.

you receive mail. This can be your street

does not have, or refuses to disclose a SSN or

address where you live or Post Office Box.

TIN. (See §6724(a))

Withholding Agent

Signature/Date: Affix your signature if the

The term "withholding agent" means any

statements in the Worker’s Certification are

Warning

person required to deduct and withhold any

true and date it.

tax under the provisions of section 1441, 1442,

This is a legal form required by the Internal

1443, or 1461.

Employer

Revenue Service by 26 CFR Sections 1.1441-

Generally, the person responsible for

Employer’s Name: Enter the name of the

5 concerning individuals claiming to be a

payment to a nonresident alien individual or

business here.

person not subject to withholding and

foreign entity is the withholding agent (see

Employer’s Address: Enter the full address

31.3402(n)-1 concerning employees incurring

§7701(a)(16) and IRS Pub. 515).

of the principal office in the country where the

no income tax liability. Failure to comply with

business is located. Also show the current

the law may lead to criminal prosecution.

Nonresident Alien Individual

mailing address if it differs from that of the

For income tax purposes, “nonresident alien

principal office.

This document was written after extensive

individual” means an individual who is neither

Employer ID #: Enter your employer ID

research into the Internal Revenue Code and

a U.S. citizen nor resident. (See IRS Pub.

number here.

other related laws by a Sovereign American

519, U.S. Tax Guide for Aliens)

Office Code: If you have an office code and

Citizen for use by those individuals not subject

wish to include it on this form you may do so

to the U.S. income tax.

Taxpayer

here.

Please feel free to copy and distribute as

The term “taxpayer” means any person subject

needed.

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