EMPLOYEE'S WITHHOLDING CERTIFICATE FOR LOCAL TAXES CITY OR COUNTY: 1. PRINT FULL NAME 2. SOCIAL SECURITY NUMBER 3. AGENCY USE 6. PLACE OF EMPLOYMENT (City, County, and State) 7. MARITAL STATUS 4. HOME ADDRESS (Street Number, City, County, State and ZIP Code) 5. DEPARTMENT-AGENCY-OFFICE Single Married SEE INSTRUCTIONS BELOW 8. CHECK PROPER BOX CITY OR COUNTY WHERE EMPLOYED 9.

Fillable Petition and Exhibit