Apply to Payroll Information - North Carolina

Payroll Information

W-4

Please review and answer the following questions regarding completion of Form W-4.

First Name *

Last Name *

Email *

Please enter email provided on original application.

2. Social Security Number *

3. Filing Status *

Note. If married, but legally separated, or spouse is a nonresident alien, select "Single".

4. Last Name Differs

If your last name differs from that shown on your social security card, check here. You must call 1-800-772-1213 for a replacement card.

5. Allowances *

Total number of allowances you are claiming (use line H on Form W-4 or applicable worksheet from Form W-4)

6. Additional Amount

Additional amount, if any, you want withheld from each paycheck.

7. Exemption

I claim exemption from withholding for 2013, and I certify that I meet both of the following conditions for exemption. 1. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and 2. This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions write "Exempt" here.

Employee's Signature *

I have reviewed the W-4 attached and I certify that under penalties of perjury, I delcare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct and complete.

State Withholding

NC-4

North Carolina Employee's Withholding Allowance Certificate: Please review and answer the following questions regarding completion of Form NC-4.

Marital Status *

SingleHead of HouseholdMarried or Qualifying Widow(er)

1. Total Allowances *

Total number of allowances you are claiming for 2014 (Enter zero (0), or the number of allowances from the table on Form NC-EZ)

2. NC Additional Amount

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

3. Exempt

I certify that I am exempt from North Carolina Withholding because I meet both of the following conditions: 1. Last year I was entitled to a refund of all State income tax withheld because I had no tax liability; AND 2. This Year, I expect a refund of all State income tax withheld because I expect to have no tax liability. If you meet both conditions write "EXEMPT" here.

4. Domiciled State

I certify that I am exempt from North Carolina withholding because I meet the requirements of the Military Spouses Residency Relief Act and I am legally domiciled in the state of: Type in name of State and "Exempt"

EXEMPT

If line 3 or line 4 above applies to you, enter the effective year. EXEMPT

5. No Longer Meet Exemption

Line 3Line 4

I certify that I no longer meet the requirements for exemption on line 3 or line 4. Therefore, I revoke my exemption and request that my employer withhold North Carolina income tax based on the number of allowances entered on line 1 and any amount entered on line 2.

CAUTION:

If you furnish an employer with an Employee's Withholding Allowance Certificate that contains information which has no reasonable basis and results in a lesser amount of tax being withheld than would have been withheld had you furnished reasonable informtion, you are subject to a penalty of 50% of the amount not properly withheld.

Employee's Signature - NC-4 *

I certify, under penalties provided by law, that I am entitled to the number of withholding allowances claimed on line 1 above, or if claiming an exemption from withholding, that I am entitled to claim the exemption status on line 3 or 4, whichever applies.

Direct Deposit *

YesNo

Would you like for us to directly deposit your paycheck into your bank account?

Bank Name

Please enter Your Bank Name

Direct Deposit Routing

If yes, please enter the Routing Number for your bank account.

Direct Deposit Account

If yes, please enter the Account Number.

Direct Deposit Type

CheckingSavings

If yes, please choose type of account.