500518
                                                              KANSAS
K-4
 (Rev. 11 8-1 )          EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE

Use the following instructions to accurately      because  you had      no tax liability; and 2)     a K-4 form from you, they must withhold 
complete  your K-4 form, then detach the          this year you will receive a full refund of all    Kansas income tax from your wages without 
lower portion and give it to your employer.       STATE  income tax withheld because you             exemption at the “Single” allowance rate.
For assistance, call the Kansas Department        will have no tax liability.                        Head of household: Generally, you may 
of Revenue at 785-368-8222.                       Basic Instructions:         If  you are not        claim  head  of  household  filing  status  on 
Purpose  of  the  K-4  form: A  completed         exempt, complete the Personal Allowance            your tax  return only if  you are                                    unmarried 
withholding allowance certificate will let your   Worksheet that follows. The total  on line F       and pay more than 50%  of the cost of 
employer know how much Kansas income tax          should not exceed the total exemptions you         keeping up a home for yourself and for 
should be withheld from your pay on income        claim under “Exemptions and Dependents”            your dependent(s).
you earn from Kansas sources. Because             on your Kansas income tax return.                  Non-wage  income:                                     If  you  have  a  large 
your tax situation may change, you may want       NOTE: Your status of “Single” or “Joint” may       amount of non-wage Kansas source income, 
to re-figure your withholding each year.          differ from your status claimed on your federal    such as interest or dividends, consider 
Exemption from Kansas withholding:                Form W-4).                                         making Kansas estimated tax payments on 
To qualify for exempt status you must verify      Using the information from your           Personal Form K-40ES. Without these payments, you 
with the Kansas Department of Revenue             Allowance Worksheet, complete the           K-4    may owe additional Kansas tax when you 
that:  1) last year you had the right to a        form  below, sign  it  and provide it  to  your    file your state income tax return.
refund of       all STATE income  tax withheld    employer. If your employer does not receive 

                                     Personal Allowance Worksheet (Keep for your records)
A Allowance Rate:  If you are a single filer mark “Single”                                                                                                            A o Single
                   If you are married and your spouse has income mark “Single”                                                                                          o Joint
                   If you are married and your spouse does not work mark “Joint”
B Enter “0” or “1” if you are married or single and no one else can claim you as a dependent (entering “0” may help
  you avoid having too little tax withheld) ......................................................................................................................... B _________
C Enter “0” or “1” if you are married and only have one job, and your spouse does not work (entering “0” may help
  you avoid having too little tax withheld) ......................................................................................................................... C _________
D Enter “2” if you will file head of household on your tax return (see conditions under Head of household above) ......... D                                            _________
E Enter the number of dependents you will claim on your tax return. Do not claim yourself or your spouse or
  dependents that your spouse has already claimed on their form K-4       ........................................................................... E                 _________
F Add lines B through E and enter the total here ........................................................................................................... F          _________

                    Cut here and give the lower portion to your employer. Keep the top portion for your records. 

                   Kansas Employee’s Withholding Allowance Certificate
                   Whether you are entitled to claim a certain number of allowances or exemption from withholding is subject to review by the
                   Kansas Department of Revenue. Your employer may be required to send a copy of this form to the Department of Revenue.

  1      Print your First Name and Middle Initial                       Last Name                                       2                               Social Security Number

         Mailing address                                                                    3 Allowance Rate
                                                                                              Mark the allowance rate selected in Line A above.
                                                                                                     o      Single                                      o  Joint

  4      Total number of allowances you are claiming (from Line F above)............................................................................... 4
  5      Enter any additional amount you want withheld from each paycheck (this is optional).................................................           5 $
  6      I claim exemption from withholding. (You must meet the conditions explained in the “Exemption from withholding”
         instructions above.) If you meet the conditions above, write “Exempt” on this line .......................................................     6
         Note: The Kansas Department of Revenue will receive your federal W-2 forms for all years claimed Exempt.
  Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief it is true, correct, and complete.
  SIGN
  HERE                                                                                                                  Date
  7      Employer’s Name and Address                                                                                    8                               EIN (Employer ID Number)