YOU HAVE ONE W4

Job 1
The W-4 Worksheet instructions and Tax Table sheets are at the end of this document. Remember, you'll need
to enter your name, Social Security Number, and address on the official W-4 form before submitting it to
your HR department.

Your W-4 has the following values.

STEP 1 SINGLE OR MARRIED FILING SEPARATELY Un-Checked

Personal Information MARRIED FILING JOINTLY Un-Checked
— Box C
HEAD OF HOUSEHOLD Checked

STEP 2 BOX 2(c) Un-Checked

Multiple jobs or
spouse works

STEP 3 LINE 1 $0
Claim dependents LINE 2 $0
LINE 3 $50

STEP 4 LINE 4(a) $0

Other Adjustments LINE 4(b) $0
LINE 4(c) $6,269

STEP 4(b) LINE 1 $0

Deductions Worksheet LINE 2 $20,800
LINE 3 $0
LINE 4 $0
LINE 5 $0
X

0
0

50

6,269
0

0
0

20,800

0
0
Your Information
Here you'll find all the information you entered into the W-4 calculator. It is essential that you bring these pages with
you for any consultation appointment that you schedule with an H&R Block tax pro.

General FILING STATUS

Head of Household
TREAT JOBS AS SIMILAR
No
LEFT A JOB THIS YEAR
No

Income Dividend Income

$0
Interest Income
$0
Unemployment Income
$0
Retirement Income
$0

JOB NAME TAX PAYER'S SPOUSE'S YEARLY YEAR TO DATE PAY

Jobs — Current
JOB JOB INCOME WITHHOLDING FREQUENCY

Job 1 Yes No $187,545 $50 Monthly

Deductions DONATIONS $0

IRA CONTRIBUTIONS $0

MEDICAL EXPENSES $0

MORTGAGE INTEREST $0

OTHER $0

STATE AND LOCAL TAXES $0

STUDENT LOAN INTEREST $0

TAKING STANDARD DEDUCTION Yes

Credits Other Credits............................................................................................................................................................ $50