Employee’s Withholding Allowance Form - Greater Home Health Services

Employee's Withholding Allowance Form

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This field is for validation purposes and should be left unchanged.

Social Security Number

Marital Status

Single

Head of Household

Married or Qualifying Widow(er)

Name

Address

County (Enter first five letters)

City

State

Zip Code (5 Digit)

Country (If not U.S.)

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 exemption from withholding, that I am entitled to claim the exempt status on line 3 or 4, whichever applies.

Employee’s Signature

Date