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Apply to Payroll Information - Indiana

Payroll Information
W-4
Please review and answer the following questions regarding completion of the Form W-4.
Please enter email provided on original application.
Note. If married, but legally separated, or spouse is a nonresident alien, select "Single".
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.
Total number of allowances you are claiming (use line H on Form W-4 or applicable worksheet from Form W-4)
Additional amount, if any, you want withheld from each paycheck.
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.
I have reviewed the W-4 attached and I have answered all questions for the Employee's Withholding Allowance Certificate
State Withholding
IN-4
Indiana Employee's Withholding Exemption and County Status Certificate: Please review and answer the following questions regarding completion of the Form IN-4.
Please Enter Indiana County of Residence as of January 1: (See instructions)
Indiana County of Principal Employment as of January 1: (See instructions)
You are entitled to one exemption. If you wish to claim the exemption, enter "1" here
If you are married and your spouse does not claim his/her exemption, you may claim it, enter "1"
You are allowed one (1) exemption for each dependent. Enter number claimed
Additional Exemptions are allowed if: a. you and/or your spouse are over the age of 65 b. if you and/or your spouse are legally blind. Add one for additional exemptions: _ you are 65 or older _ or blind _ Spouse is 65 or older _ or blind
Add lines 1, 2, 3, and 4. Enter Total Here
You are entitled to claim an additional exemption for each qualifying dependent (see instructions)
Enter the amount of additional state withholding (if any) you want withheld each pay period
Enter the amount of additional county withholding (if any) you want withheld each pay period
Direct Deposit *
Would you like for us to directly deposit your paycheck into your bank account?
Please enter Your Bank Name
If yes, please enter the Routing Number for your bank account.
If yes, please enter the Account Number for your bank account.
Direct Deposit Type
If yes, please choose type of account.