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                                       Instructions  For Employee Withholding Certificate 

Dependents     - To qualify as your dependent (line                                                     Other  Decreases -  in  exemptions,  such  as  the 
7a ) a person must qualify as your dependent as                                                         death  of  a  spouse  or  dependent,  do  not  affect 
provided in the Federal Internal Revenue Code.                                                          your  withholdings  until  the  next  year  but  require 
                                                                                                        the filing of a new certificate by December 1 of the 
                                                                                                        year in which they occur. 
Changes in Exemptions          - You should file a new 
certificate  any  time  the  number  of    your                                                         Change  of  Residence           -  You  must  file  a  new 
exemptions  increases.  You  must  file  a  new                                                         certificate  within  10  days  after  you  change  your 
certificate  within  10  days  if  the  number  of                                                      residence from or to a taxing city. 
exemptions     previously      claimed by             you 
DECREASES.                                                                                              Additional  withheld            -  You  may  designate  additional
                                                                                                        withholding  if  you  expect  to  owe  more  than  the  amount 
                                                                                                        withheld. 

                                                           EMPLOYEES WITHOLDING CERTIFICATE 
                                                           FOR THE CITY OF SPRINGFIELD INCOME TAX                                                                 SF W-4 

1. Print full name                                         2. Social Security Number                          3. Springfield Resident?  Yes

                                                                                                                                                                  No 

4. Address                                                              City, Township or Village where you reside                      State                     Zip Code 

                               Check boxes that apply
Employee - File this form 
with your employer,            5. Exemptions for yourself: Regular      Age 65 & older                  Blind     Deaf                  Enter number of 
otherwise your employer                                    Exemption    or Disabled                                                     exemptions checked
must withhold Springfield      6. Exemptions for your      Regular      Age 65 & older                  Blind     Deaf                  Enter number of 
income tax from your           spouse:                     Exemption    or Disabled                                                     exemptions checked
earnings without exemptions.   7a. Exemptions for your children  Number 7b. Exemptions for your other dependents Number                 Enter total of line 
                                                                                                                                        7 (a plus b)
Employer - Keep this 
certificate with your records. 8. Add the number of exemptions which you have claimed on lines 5, 6, 7 a & b above and write the total.       Total 
If the information submitted 
by the employee is not 
believed to be true, correct   8. Additional amount you want deducted from each pay (if employer agrees)
and complete, the Springfield  I certify that the information submitted on this certificate is true, correct and complete to the best of my knowledge and belief. 
Income Tax Department must 
be so advised.                 Date                        Signature