Form W-4 (2004). Summary: This is an example of Form W-4 (2004) with items included as described in the text. Additionally, these line items
are
completed:
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“1. Type or print your first name and middle initial” field contains John M.
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“Last name” field contains Green
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“Home address (number and street or rural route)” field contains 28 Fairway
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“City or town, state, and ZIP code” field contains Anytown, State 00000
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“2. Your social security number” field contains 444-00-4444
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“3. Married” checkbox checked
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“Employee's signature (Form is not valid unless you sign it.)” field contains John M. Green
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“Date” field contains January 4, 2004
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