Print Form
Submit this information online at www.iowachildsupport.gov
...or mail this portion of the page to Centralized Employee Registry, PO Box 10322, Des Moines IA 50306-0322; or fax to 1-800-759-5881.
Centralized Employee Registry Reporting Form
TO BE COMPLETED BY THE EMPLOYER within 15 days of hire. Please Print or Type. EMPLOYER INFORMATION FEIN Required
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Telephone Number:
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FEIN plus last 3-digit suffix used when filing Iowa withholding tax. Name: ____________________________________________________________________________________________ Address: __________________________________________________________________________________________ City: __________________________________ State: ZIP:
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Questions: For A through D below, please see instructions on back for definitions and clarification. A. Is dependent health care coverage available? Yes or No
MM MM DD YYYY DD YYYY
B. Approximate date this employee qualifies for coverage: C. Employee start date:
D. Address where income withholding and garnishment orders should be sent, if different than above address. Address: _____________________________________________________________________________________ City: _____________________________ State: EMPLOYEE INFORMATION Employee’s Date of Birth:
MM DD YYYY
ZIP:
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Employee’s Social Security Number:
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Last Name: __________________________ First Name: ______________________ Middle Initial: _______ Address: ________________________________________________________________________________________ City: ________________________________ State: ______ ZIP: ______________
Iowa Department of Revenue www.iowa.gov/tax
Marital status: Print your full name Single Married (If married but legally separated, check Single.)
2013 IA W-4
Employee Withholding Allowance Certificate
To be completed by the employee
Social Security Number: ________________________________
Home Address: ______________________________________________________ City:_____________________ State:_______ ZIP: ____________ EXEMPTION FROM WITHHOLDING. If you do not expect to owe any Iowa income tax this year, and expect to have a right to a full refund of ALL income tax withheld, enter “EXEMPT” here: _______________ and the year effective here: ________ Nonresidents may not claim this exemption. Check this box if you are claiming exemption from Iowa tax based on the Military Spouses Residency Relief Act of 2009. If claiming the military spouse exemption, enter your state of domicile here: _____________________________ IF YOU ARE NOT EXEMPT, COMPLETE THE FOLLOWING: 1. Personal allowances ................................................................................................................................................................... 1. ______________ 2. Allowances for dependents ........................................................................................................................................................ 2. ______________ 3. Allowances for itemized deductions .......................................................................................................................................... 3. ______________ 4. Allowances for adjustments to income ...................................................................................................................................... 4. ______________ 5. Allowances for child and dependent care credit ....................................................................................................................... 5. ______________ 6. Total allowances. Add lines 1 through 5. .................................................................................................................................. 6. ______________ 7. Additional amount, if any, you want deducted each pay period ............................................................................................. 7.
