Employee's Withholding Certificate

Maria S DSouza MS MD · 13803 Madera Run Parkway #604, Humble, TX 77346

Instructions

Complete Steps 1 through 4. Steps 2 through 4 are optional, but completing them will help ensure your federal income tax withholding more accurately matches your tax liability. If you claim exemption from withholding, certify that you meet both of the following conditions: (1) You had no federal income tax liability in the prior year, and (2) You expect to have no federal income tax liability in the current year.

1Enter Personal Information

First Name *

Middle Initial

Last Name *

Social Security Number *

Address (Number, Street, and Apt. or Suite No.)

City or Town, State, and ZIP Code

Filing Status *

Single or Married filing separatelyMarried filing jointly or Qualifying surviving spouseHead of household (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual)

2Multiple Jobs or Spouse Works (optional)

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.

Check here if there are only two jobs total. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld.

3Claim Dependents (optional)

If your total income will be $200,000 or less ($400,000 or less if married filing jointly), complete the fields below.

Qualifying children under age 17 — number of children

Multiply by $2,000 = $0

Other dependents — number of dependents

Multiply by $500 = $0

Total: Add the amounts above and enter here → $0

4Other Adjustments (optional)

(a) Other income (not from jobs). Enter the amount of other income you expect this year that won't have withholding. Examples: interest, dividends, retirement income.

(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet and enter the result here.

5Sign Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

Print Full Name *

Today's Date

Employee Signature *

Sign here

Draw your signature above

Employer's Name and Address

Maria S DSouza MS MD · 13803 Madera Run Parkway #604, Humble, TX 77346

First date of employment: _____________________ | Employer identification number (EIN): _____________________

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