WEST VIRGINIA EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE 
                              FORM WV/IT-104 

Complete this form and present it to your employer to avoid any delay in adjusting the amount of state 
income tax to be withheld from your wages. 

      If you do not complete this form, the amount of tax that is now being withheld from your pay may not be 
sufficient to cover the total amount of tax due the state when filing your personal income tax return after the 
close of the year. You may be subject to a penalty on tax owed the state. 

Individuals are permitted a maximum of one exemption for themselves, plus an additional exemption for 
their spouse and any dependent other than their spouse that they expect to claim on their tax return. 

      If you are married and both you and your spouse work and you file a joint income tax return, or 
if you are working two or more jobs, the revised withholding tables should result in a more accurate 
amount of tax being withheld. 

If you are Single, Head of Household, or Married and your spouse does not work, and you are receiving 
wages from only one job, and you wish to have your tax withheld at a lower rate, you must check the box on 
line 5. 

When requesting withholding from pension and annuity payments you must present this completed form 
to the payor. Enter the amount you want withheld on line 6. 

         If you determine the amount of tax being withheld is insufficient, you may reduce the number of 
exemptions you are claiming or request additional taxes be withheld from each payroll period. Enter the 
additional amount you want to have withheld on line 6. 
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WV/IT-104      WEST VIRGINIA EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE 
Rev. 12/09 

Name                                                  Social Security Number 

Address  

City                          State                                          Zip Code  

      1.   If SINGLE, and you claim an exemption, enter “1”, if you do not, enter “0 ..........................................
      2.   If MARRIED, one exemption each for husband and wife if not claimed on another certificate.
           (a)  If you claim both of these exemptions, enter “2” 
           (b) If you claim one of these exemptions, enter “1”      ........................................ 
           (c) If you claim neither of these exemptions, enter “0” 
      3.   If you claim exemptions for one or more dependents, enter the number of such exemptions. ...........
      4.   Add the number of exemptions which you have claimed above and enter the total ............................
      5.   If you are Single, Head of Household, or Married and your spouse does not work, and you are receiving
           wages from only one job, and you wish to have your tax withheld at a lower rate, check here ........... 
      6.   Additional withholding per pay period under agreement with employer, enter amount here .............. $
Note that special withholding allowances provided on Federal Form W-4 may not be claimed on your West Virginia Form WV/IT-104 I CERTIFY, 
under penalties provided by law, that the number of exemptions claimed in this certificate is not in excess of those to which I am entitled. 

Date                                                              Signature  
                              NONRESIDENTS-SEE REVERSE SIDE 

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 WV/IT-104                            WEST VIRGINIA CERTIFICATE OF NONRESIDENCE 
 Rev. 12/09 
 
 This form is to be completed by employees who reside in Kentucky, Maryland, Ohio, Pennsylvania, Virginia or by an employee who is a Military 
 Spouse exempt from income tax on wages. 
 
 If you are a resident of Kentucky, Maryland, Ohio, Pennsylvania or Virginia and your only source of income from West Virginia is wages or salaries, 
 you are exempt from West Virginia Personal Income Tax Withholding. Upon receipt of this form, properly completed, your employer is authorized 
 to discontinue the withholding of West Virginia Income Tax from your wages or salaries earned in West Virginia. 
 
 If you are a military spouse and (a) your spouse is a member of the armed forces present in West Virginia in compliance with military orders; (b) 
 you are present in West Virginia solely to be with your spouse; and (c) you maintain your domicile in another State and you are claiming exemption 
 under the Servicemember Civil Relief Act, enter your state of domicile (legal residence) on the following statement and attach a copy of your 
 spousal military identification card.
 
 I certify that I am a legal resident of the state of        and am not subject to West Virginia withholding because l meet the requirements 
 set forth under the Servicemembers Civil Relief Act, as amended by the Military Spouses Residency Relief Act. 
 
 Name                                                  Social Security Number                                                 
 Address                                                                                                                      
 City                                                 State                      Zip Code                                      
 
 I hereby certify, under penalties provided by law, that I am not a resident of West Virginia, that I reside in the State of  and live 
 at the address shown on this certificate, and request is hereby made to my employer to NOT withhold West Virginia income tax from wages paid 
 to me. If at any time hereafter I become a resident of West Virginia, or otherwise lose my status of being exempt from West Virginia withholding 
 taxes, I will properly notify my employer of such fact within ten (10) days from the date of change so that my employer may then withhold West 
 Virginia income tax from my wages. 
 
 I certify that the above statements are true, correct, and complete. 
 
 Date                                 Signature