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GR W-4 Employee’s Withholding Certificate For City of Grayling ❒ RESIDENT
Income Tax ❒ NON-RESIDENT
1. Print Full Name Social Security No. Office, Plant Dept. Employee Identification No.

2. Address, Number and Street City, Township or Village where you reside State Zip Code

3. Predominant Place of Employment City Under
Print name of each city where you work for this 25% 40% 60% 80% 100%
employer and circle closest % of total earnings City Under
in each. 25% 40% 60% 80% 100%
YOUR WITHHOLDING Check 4. Exemptions Regular $3000 Additional $3,000 exemption if Additional $3,000 Enter number of
exemptions
EXEMPTIONS: blocks for yourself exemption 65 or over at end of year exemption if blind checked
(See instructions on which 5. Exemptions Regular $3000 Additional $3,000 exemption if Additional $3,000 Enter number of
exemptions
reverse side.) apply } for your wife (husband) exemption 65 or over at end of year exemption if blind checked
EMPLOYEE: File this form with your employer. 6. (a) Exemptions for your Number 6. (b) Exemptions for your Number Enter total
of line 6
Otherwise he must withhold CITY OF children other dependents (a plus b)
GRAYLING income tax from your earnings with-
out exemption. 7. Add the number of exemptions which you have claimed on lines 4,5 and 6 above and write the total
EMPLOYER: keep this certificate with your
records. If the information submitted by the I certify that the information submitted on this certificate is true, correct and complete to the best of my knowledge and belief.
employee is not believed to be true, correct and
complete. The City Treasurer must be so 8. Date Signature
advised. 20

GR W-4 Employee’s Withholding Certificate For City of Grayling ❒ RESIDENT
Income Tax ❒ NON-RESIDENT
1. Print Full Name Social Security No. Office, Plant Dept. Employee Identification No.

2. Address, Number and Street City, Township or Village where you reside State Zip Code

GR W-4 Employee’s Withholding Certificate For City of Grayling ❒ RESIDENT
Income Tax ❒ NON-RESIDENT
1. Print Full Name Social Security No. Office, Plant Dept. Employee Identification No.

2. Address, Number and Street City, Township or Village where you reside State Zip Code

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LINE 3 INSTRUCTIONS – If you work for this employer in more than two cities                   CHANGES IN EXEMPTIONS – You should file a new certificate at any time if
or communities, print names of the two Michigan cities or communities where                   the number of your exemptions INCREASES. 
you perform the greatest percent of your work. Circle the closest percent of total            You must file a certificate within 10 days if the number of exemptions previously
earnings for work done or services rendered in each city or community listed.                 claimed by you DECREASES for any of the following reasons:
The estimated percent of total earnings from this employer for work done or                   (a) Your wife (or husband) for whom you have been claiming 
services performed within taxing cities (line 3 on other side) is for withholding             exemption is divorced or legally separated, or claims her (or his) 
purposes only. In determining final tax liability this estimate is subject to sub-            own exemption on a separate certificate.
stantiation and audit.                                                                        (b) The support of a dependent for whom you claimed exemption is 
DEPENDENTS – To qualify as you dependent (line 6 on other side), a person                     taken over by someone else, so that you no longer expect to 
(a) must receive more than one-half of his or her support from you for the year,              furnish more than half the support for the year.
and (b) must have less than $3,000 gross income during the year (except your                  (c) You find that a dependent for whom you claimed exemption will 
child who is a student or who is under 19 years of age) and (c) must not be                   receive $3,000 or more of income of his own during the year 
claimed as an exemption by such person’s husband or wife, and (d) must be a                   (except your child who is a student who is under 19 years of age).
citizen or resident of the United States or a resident of Canada, Mexico, the                 OTHER DECREASES in exemption, such as the death of a wife or a depend-
Republic of Panama or the Canal Zone (this does not apply to an alien child                   ent, do not affect your withholding until the next year, but require the filing of a
legally adopted by and living with a United States citizen abroad) and (e) must               new certificate by December 1 of the year in which they occur.
(1) have your home as his principal residence and be a member of you house-
hold for the entire year, or (2) be related to you as follows:                                CHANGE OF RESIDENCE – You must file a new certificate within 10 days after
Your son or daughter (including legally adopted children), grandchild, stepson, stepdaughter, you change your residence from or to a taxing city.
son-in-law or daughter-in-law;
Your father, mother, grandparent, stepfather, stepmother, father-in-law, or mother-in-law     CHANGES IN EMPLOYMENT– You must file a new certificate by December 1
Your brother, sister, stepbrother, stepsister, half brother, half sister, brother-in-law or 
sister-in-law;                                                                                each year if your Line 3 estimate of the percent of work done or services to be
Your uncle, aunt, nephew or niece (but only if related by blood).                             rendered in cities levying as income tax will change for the ensuing year.

LINE 3 INSTRUCTIONS – If you work for this employer in more than two cities                   CHANGES IN EXEMPTIONS – You should file a new certificate at any time if
or communities, print names of the two Michigan cities or communities where                   the number of your exemptions INCREASES. 
you perform the greatest percent of your work. Circle the closest percent of total            You must file a certificate within 10 days if the number of exemptions previously
earnings for work done or services rendered in each city or community listed.                 claimed by you DECREASES for any of the following reasons:
The estimated percent of total earnings from this employer for work done or                   (a) Your wife (or husband) for whom you have been claiming 
services performed within taxing cities (line 3 on other side) is for withholding             exemption is divorced or legally separated, or claims her (or his) 
purposes only. In determining final tax liability this estimate is subject to sub-            own exemption on a separate certificate.
stantiation and audit.                                                                        (b) The support of a dependent for whom you claimed exemption is 
DEPENDENTS – To qualify as you dependent (line 6 on other side), a person                     taken over by someone else, so that you no longer expect to 
(a) must receive more than one-half of his or her support from you for the year,              furnish more than half the support for the year.
and (b) must have less than $3,000 gross income during the year (except your                  (c) You find that a dependent for whom you claimed exemption will 
child who is a student or who is under 19 years of age) and (c) must not be                   receive $3,000 or more of income of his own during the year 
claimed as an exemption by such person’s husband or wife, and (d) must be a                   (except your child who is a student who is under 19 years of age).
citizen or resident of the United States or a resident of Canada, Mexico, the                 OTHER DECREASES in exemption, such as the death of a wife or a depend-
Republic of Panama or the Canal Zone (this does not apply to an alien child                   ent, do not affect your withholding until the next year, but require the filing of a
legally adopted by and living with a United States citizen abroad) and (e) must               new certificate by December 1 of the year in which they occur.
(1) have your home as his principal residence and be a member of you house-
hold for the entire year, or (2) be related to you as follows:                                CHANGE OF RESIDENCE – You must file a new certificate within 10 days after
Your son or daughter (including legally adopted children), grandchild, stepson, stepdaughter, you change your residence from or to a taxing city.
son-in-law or daughter-in-law;
Your father, mother, grandparent, stepfather, stepmother, father-in-law, or mother-in-law     CHANGES IN EMPLOYMENT– You must file a new certificate by December 1
Your brother, sister, stepbrother, stepsister, half brother, half sister, brother-in-law or 
sister-in-law;                                                                                each year if your Line 3 estimate of the percent of work done or services to be
Your uncle, aunt, nephew or niece (but only if related by blood).                             rendered in cities levying as income tax will change for the ensuing year.

LINE 3 INSTRUCTIONS – If you work for this employer in more than two cities                   CHANGES IN EXEMPTIONS – You should file a new certificate at any time if
or communities, print names of the two Michigan cities or communities where                   the number of your exemptions INCREASES. 
you perform the greatest percent of your work. Circle the closest percent of total            You must file a certificate within 10 days if the number of exemptions previously
earnings for work done or services rendered in each city or community listed.                 claimed by you DECREASES for any of the following reasons:
The estimated percent of total earnings from this employer for work done or                   (a) Your wife (or husband) for whom you have been claiming 
services performed within taxing cities (line 3 on other side) is for withholding             exemption is divorced or legally separated, or claims her (or his) 
purposes only. In determining final tax liability this estimate is subject to sub-            own exemption on a separate certificate.
stantiation and audit.                                                                        (b) The support of a dependent for whom you claimed exemption is 
DEPENDENTS – To qualify as you dependent (line 6 on other side), a person                     taken over by someone else, so that you no longer expect to 
(a) must receive more than one-half of his or her support from you for the year,              furnish more than half the support for the year.
and (b) must have less than $3,000 gross income during the year (except your                  (c) You find that a dependent for whom you claimed exemption will 
child who is a student or who is under 19 years of age) and (c) must not be                   receive $3,000 or more of income of his own during the year 
claimed as an exemption by such person’s husband or wife, and (d) must be a                   (except your child who is a student who is under 19 years of age).
citizen or resident of the United States or a resident of Canada, Mexico, the                 OTHER DECREASES in exemption, such as the death of a wife or a depend-
Republic of Panama or the Canal Zone (this does not apply to an alien child                   ent, do not affect your withholding until the next year, but require the filing of a
legally adopted by and living with a United States citizen abroad) and (e) must               new certificate by December 1 of the year in which they occur.
(1) have your home as his principal residence and be a member of you house-
hold for the entire year, or (2) be related to you as follows:                                CHANGE OF RESIDENCE – You must file a new certificate within 10 days after
Your son or daughter (including legally adopted children), grandchild, stepson, stepdaughter, you change your residence from or to a taxing city.
son-in-law or daughter-in-law;
Your father, mother, grandparent, stepfather, stepmother, father-in-law, or mother-in-law     CHANGES IN EMPLOYMENT– You must file a new certificate by December 1
Your brother, sister, stepbrother, stepsister, half brother, half sister, brother-in-law or 
sister-in-law;                                                                                each year if your Line 3 estimate of the percent of work done or services to be
Your uncle, aunt, nephew or niece (but only if related by blood).                             rendered in cities levying as income tax will change for the ensuing year.

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