STATE OF LEGAL RESIDENCE CERTIFICATE

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY:

PURPOSE:

ROUTINE USES:

MANDATORY ORVOLUNTARYDISCLOSURE:

Tax Reform Act of 1976, Public Law 94-455.

Information is required for determining the correct State of legal residence for purposes of withholdingState income taxes from military pay.

Information herein will be furnished State authorities and to Members of Congress.

Disclosure is voluntary. If not provided, State income taxes will be withheld based on the tax laws of theState previously certified as your legal residence, or in the absence of a prior certification, the tax laws ofthe applicable State based on your home of record.

NAME (Last, first, middle initial) SOCIAL SECURITY NUMBER (SSN)

LEGAL RESIDENCE/DOMICILE (City or county and State)

INSTRUCTIONS FOR CERTIFICATION OF STATE OF LEGAL RESIDENCE

The purpose of this certificate is to obtain information with respect to your legal residence/domicile for the purpose of determiningthe State for which income taxes are to be withheld from your "wages" as defined by Section 3401(a) of the Internal Revenue Codeof 1954. PLEASE READ INSTRUCTIONS CAREFULLY BEFORE SIGNING.

The terms "legal residence" and "domicile" are essentially interchangeable. In brief, they are used to denote that place where youhave your permanent home and to which, whenever you are absent, you have the intention of returning. The Soldiers’ and Sailors’Civil Relief Act protects your military pay from the income taxes of the State in which you reside by reason of military orders unlessthat is also your legal residence/domicile. The Act further provides that no change in your State of legal residence/domicile willoccur solely as a result of your being ordered to a new duty station.

You should not confuse the State which is your "home of record" with your State of legal residence/domicile. Your "home ofrecord" is used for fixing travel and transportation allowances. A "home of record" must be changed if it was erroneously orfraudulently recorded initially.

Enlisted members may change their "home of record" at the time they sign a new enlistment contract. Officers may not change their"home of record" except to correct an error, or after a break in service. The State which is your "home of record" may be your Stateof legal residence/domicile only if it meets certain criteria.

The formula for changing your State of legal residence/domicile is simply stated as follows: physical presence in the new State withthe simultaneous intent of making it your permanent home and abandonment of the old State of legal residence/domicile. In most cases, you must actually reside in the new State at the time you form the intent to make it your permanent home. Such intentmust be clearly indicated. Your intent to make the new State your permanent home may be indicated by certain actions such as: (1)registering to vote; (2) purchasing residential property or an unimproved residential lot; (3) titling and registering yourautomobile(s); (4) notifying the State of your previous legal residence/domicile of the change in your State of legalresidence/domicile; and (5) preparing a new last will and testament which indicates your new State of legal residence/domicile. Finally, you must comply with the applicable tax laws of the State which is your new legal residence/domicile.

Generally, unless these steps have been taken, it is doubtful that your State of legal residence/domicile has changed. Failure toresolve any doubts as to your State of legal residence/domicile may adversely impact on certain legal privileges which depend onlegal residence/domicile including among others, eligibility for resident tuition rates at State universities, eligibility to vote or be acandidate for public office, and eligibility for various welfare benefits. If you have any doubt with regard to your State of legalresidence/domicile, you are advised to see your Legal Assistance Officer (JAG Representative) for advice prior to completing thisform.

I certify that to the best of my knowledge and belief, I have met all the requirements for legal residence/domicile in the State claimedabove and that the information provided is correct.

I understand that the tax authorities of my former State of legal residence/domicile will be notified of this certificate.

SIGNATURE DATECURRENT MAILING ADDRESS (Include ZIP Code)

DD Form 2058, FEB 77 (EG) Designed using Perform Pro, WHS/DIOR, Jul 94

DOE, JOHN A. 123-45-6789

CHAPEL HILL or ORANGE COUNTY, NC

SIGN SELF EXPLANATORY LEAVE BLANK

GL.2010.094 Ed. 06/2014 SGLV 8286

1. About You

3. About Your Beneficiaries Complete this section unless you are declining coverage

Print Name (First, Middle, Last) Rank, title or grade Social Security Number

Duty Location Branch of Service Current Amount of SGLI

I am completing this form to: (Check all that apply)

Name or update my SGLI beneficiary. You must complete sections 3 & 5.

Increase or restore my SGLI coverage to $

Reduce my SGLI coverage to $

Decline or cancel SGLI coverage. Write below “ I do not want insurance at this time.” You must complete section 5.

Coverage is available in

increments of $50,000 up to a maximum of $400,000

Servicemembers’ Group Life Insurance Election and Certificate

Have more beneficiaries? Check the box and complete Supplemental SGLI Beneficiary Form, SGLV 8286S.If you do not name beneficiaries above, your insurance will be paid by law (see page 3). * If the insured member elects a lump sum payment, the beneficiary(ies) will be given the option of receiving the lump sum payment through the Prudential

Alliance Account®, by check, or Electronic Funds Transfer (EFT). Alliance Account is not available for payments less than $5,000, payments to individuals residing outside the United States and its territories, and certain other payments. These will be paid by check.

Share to each (% or $ amounts)

Payment Option (Lump sum* or 36 equal monthly payments)

Primary Name and Address

Social Security Number (If available)

Relationship to you

1.

2.

3.

4.

Secondary

1.

2.

3.

4.

2. About Your Coverage

Page 1 of 4

Office of Servicemembers' Group Life Insurance

. You must complete sections 3, 4, & 5.

. You must complete sections 3 & 5.

“ .”

The Bank of New York Mellon is the Administrator of the Prudential Alliance Account Settlement Option, a contractual obligation of The Prudential Insurance Company of America, located at 751 Broad Street, Newark, NJ 07102-3777. Draft clearing and processing support is provided by The Bank of New York Mellon. Alliance Account balances are not insured by the Federal Deposit Insurance Corporation (FDIC). The Bank of New York Mellon is not a Prudential Financial company.

JOHN ANTONIO DOE (IF NO MIDDLE NAME ENTER NMN) CADET 123-45-6789

DET 590 AIR FORCE 0

I DO NOT WANT INSURANCE AT THIS TIME

GL.2010.094 Ed. 06/2014 SGLV 8286 Page 2 of 4

I have read the instructions and understand that:

This form cancels any prior beneficiary or payment instructions.I can have SGLI and Veterans’ Group Life Insurance (VGLI) coverage at the same time, but the combined amount cannot be more than $400,000.

Reducing or declining SGLI coverage can affect the amount of my family coverage, traumatic injury coverage and post-separation coverage (see instructions for details).If I am married or get married after completing this form and have not declined SGLI, spouse SGLI automatically covers my spouse. If my spouse is also a member of the uniformed services and we were married on or after January 2, 2013, spouse SGLI coverage is not automatic, but I may apply for spouse coverage by completing SGLV 8286A. I must register my spouse in DEERS so my branch of service can deduct premiums from my pay. Failure to register my spouse in DEERS will result in my owing debts for unpaid premiums. I can decline spouse SGLI coverage by completing SGLV 8286A.

I am free to name anyone I want as my beneficiary. I certify that I understand if I have designated someone other than my spouse or child as my beneficiary, the person I have named is the person I intend to receive my insurance proceeds. I also understand that if I am married, my spouse may be notified that he/she (or my child) is not my designated beneficiary.

I certify that the information provided on this form is true and correct to the best of my knowledge and belief. Any deception or knowingly false statement either by inference or omission may result in cancellation of the insurance or in the refusal to pay a claim.

5. Your Signature You must complete this section.

Service Member Signature Social Security Number Date (MM, DD, YYYY)

For Branch of Service Use Only

Name of Personnel Clerk Representative

Rank, title or grade Approve

Contact telephone/email Disapprove

Date Date

Address

For OSGLI Use Only

Address

4. About Your Health Complete this section ONLY if you are restoring or increasing coverage.

Your date of birth (MM, DD, YYYY) Your weight Your height

Have you had, been treated for, or had known indications of: Yes Noa. A heart condition?

b. High blood pressure? c. A neurological disorder? d. Diabetes?

e. Cancer or tumors? f. Have you ever been diagnosed as having a disease of the immune system? g. Do you have any known physical impairments,

deformities, or ill health not covered above?

Your gender FemaleMale

Did you answer “YES” to any question? If so, reference the question by letter and list date, duration and details below.

If you answered yes to any question above, your request to increase coverage will not take effect until approved by the Office of Servicemembers’ Group Life Insurance (OSGLI). If you answered no to all the questions above, your request for increased coverage takes effect immediately.

Submit this form to your Unit Personnel Clerk.

SIGN HERE 123-45-6789 LEAVE BLANK

SELF-EXPLANATORY

GL.2010.094 Ed. 06/2014 SGLV 8286

Instructions for Personnel Clerk and the Service Member1. A representative of the Uniformed Services must complete the “For Branch of Service Official Use Only” section to indicate receipt of the

form from the member after reviewing the following table:

If the service member…The Personnel Clerk should inform the service member… Then the Personnel Clerk should…

has just entered the service he or she is automatically insured for $400,000 SGLI, unless the service member declines or reduces coverage.

have the service member designate beneficiaries by completing SGLV 8286.

is increasing or restoring SGLI he or she must complete Section 4, About Your Health. approve form if the responses to questions 4a through 4g are “No” and forward the form to payroll to change SGLI premium deductions.send form to OSGLI if any answer to questions 4a through 4g are “Yes.” Only inform payroll when approved by OSGLI.

Reduces, declines, or cancels SGLI

an application with health questions is required to increase, elect, or restore coverage at a later date.

of the following: – the purpose and role of life insurance in financial planning.– the difference between term life insurance and whole life insurance.– the availability of commercial life insurance.– the relationship between SGLI and VGLI.– declining or canceling SGLI will also cancel Family SGLI— both

spouse and dependent child coverage— and Traumatic Injury Protection (TSGLI).

forward the form to payroll to change SGLI premium deductions.

if canceling SGLI, have the service member complete SGLV 8286A to end payment of Family SGLI premiums. No form is required to end TSGLI premium deductions.if the member is married and reduces, declines, or cancels SGLI, inform the member that his her spouse may be notified in writing of the member’s election based on Title 38, USC 1967 (f).

is married or gets married after completing this form (and is not married to another member of the uniformed services)

gets married to another member of the uniformed services on or after January 2, 2013

spouse SGLI automatically covers spouse.he or she must register their spouse in DEERS for payroll to deduct premiums.

If the member wants to decline coverage or take a lesser amount of spouse coverage, the member must complete SGLV 8286A.

if applicable, forward the form to payroll to begin premium deductions for the spouse coverage.

if member wants spouse SGLI coverage, provide the member with SGLV 8286A, Spouse Coverage Election and Certificate, and follow the instructions therein.

spouse SGLI coverage is not automatic and the member may apply for spouse SGLI coverage by completing SGLV 8286A.

has questions about this form the advice of a military attorney is available at no expense. direct them to the appropriate resource.

wants to designate more beneficiaries than the form allows

he or she must complete the Supplemental SGLI Beneficiary Form SGLV 8286S.

attach the Supplemental Beneficiary Form to the 8286.

designates any person other than his/ her spouse or child for any amount of insurance

while the member is free to designate anyone he or she chooses as beneficiary, the member must certify that he or she is designating someone other than a spouse or child and the person named will receive the benefit.

if the member is married, the member’s spouse will be notified in writing that he/she or the member’s child is not the named beneficiary, unless:– the spouse has been previously notified, OR– the spouse is not designated as beneficiary for any

amount of insurance prior to the new election.

have the member sign SGLV 8286 to certify that he/she understands that:

he/she is free to name anyone as beneficiary.

if he/she designated someone other than his/her spouse or child as beneficiary, the person the member has named is the person he/she intends to receive the insurance proceeds.

if married, the spouse will be notified that he/she (or any child) is not the designated beneficiary.

Page 4 of 427305-1012

2. After the form is completed, Personnel Clerk should:

File a copy in the member’s official personnel file

Provide a copy to the service member

Provide a copy of the form to the payroll office for the member’s unit

Submit the form to OSGLI ONLY if the member is increasing or restoring SGLI coverage and answered “Yes” to one or more of the health questions

OSGLI PO Box 41618 Philadelphia, PA 19176-9913

GL.2010.094 Ed. 06/2014 SGLV 8286

Information for the Service MemberAbout your SGLI CoverageServicemembers’ Group Life Insurance (SGLI) is granted under title 38, United States Code, and is subject to the provisions of that title and its amendments, and title 38 Code of Federal Regulations.

The following charts provide information you should review before naming a beneficiary or selecting a payment option.

Naming Beneficiaries who will receive the insurance

If you… Then…are married and decline coverage upon entry into service

your spouse will be notified that you declined coverage.

are married and designate any person other than your spouse or child for any amount of insurance

your spouse will be notified in writing that he/she or your child is not the named beneficiary, unless:– your spouse has been previously notified, OR – your spouse is not designated as beneficiary for any amount of insurance prior to the new election.

are married and your spouse is designated as beneficiary and you decline coverage or elect less than maximum coverage, and that election reduces your coverage from the automatic maximum or from a previously elected amount of coverage

your spouse will be notified in writing of your election to decline or reduce coverage.

have any life event such as marriage, divorce, or children after completing this form

you should complete a new beneficiary form. Beneficiaries are not automatically changed by life events.

name more than one beneficiary the sum of the shares must equal 100% or the full dollar amount of your insurance.

want to name more than four primary or secondary beneficiaries

you must complete the SGLI Supplemental Beneficiary Form, SGLV 8286S.

name minors as beneficiaries SGLI will pay the insurance benefit to the court-appointed guardian of the children’s estate if the beneficiary is a minor at time of claim.

you can establish a trust for the benefit of the children and name the trust as beneficiary. A trust names a trustee of your choice to be legally responsible for administering the insurance proceeds for the children.

naming a trust as a beneficiary on this form does NOT create a trust.

name more than one primary beneficiary and one or more of them predeceases you

SGLI will pay the shares equally among the remaining primary beneficiaries.

want to name a Trust as a beneficiary you must create a trust. Please consult with a military attorney, professional financial planner, or estate planner to help you create Trust documents. (Please note: Trust documents are not needed until a claim is submitted.)

have no surviving primary beneficiaries SGLI will divide the insurance benefit among the secondary beneficiaries.

do not name a beneficiary or there are no surviving primary or secondary beneficiaries OR indicate that payment should be made by law

SGLI will pay the insurance benefit in the following order:1. Widow or widower2. Children in equal shares (the share of any deceased child will be distributed equally among the

descendants of that child)3. Parent(s) in equal shares or all to surviving parent4. A duly appointed executor or administrator of your estate5. Other next of kin

Payment Options

If you want the beneficiary to… Then…

receive the insurance proceeds in one lump sum

write the phrase “lump sum” under Payment Options. If you elect a lump sum payment, your beneficiary(ies) will be given the option of receiving the lump sum payment through the Prudential Alliance Account®*, by check, or Electronic Funds Transfer (EFT).

* Alliance Account is not available for payments less than $5,000, payments to individuals residing outside the United States and its territories, and certain other payments. These will be paid by check.

receive the insurance proceeds in 36 equal monthly payments

write “36” under the Payment Option.

your beneficiary cannot change this payment option.

have a choice write the phrase “lump sum” under Payment Option or leave blank.

Page 3 of 4

}

{

Form W-4 (2016) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2016 expires February 15, 2017. See Pub. 505, Tax Withholding and Estimated Tax. Note: If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee: • Is age 65 or older,

• Is blind, or

• Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions do not apply to supplemental wages greater than $1,000,000. Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information. Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details. Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2016. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married). Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.) A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: {• You are single and have only one job; or• You are married, have only one job, and your spouse does not work; or• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

. . . B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E

F Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F (Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)

G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. • If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if youhave two to four eligible children or less “2” if you have five or more eligible children. • If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . . G

H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) ▶ H

For accuracy, complete all worksheets that apply.

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductionsand Adjustments Worksheet on page 2.

• If you are single and have more than one job or are married and you and your spouse both work and the combinedearnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2to avoid having too little tax withheld.

• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate ▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding issubject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

2016 1 Your first name and middle initial Last name 2 Your social security number

Home address (number and street or rural route) 3 Single Married Married, but withhold at higher Single rate. Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

City or town, state, and ZIP code 4 If your last name differs from that shown on your social security card,

check here. You must call 1-800-772-1213 for a replacement card. ▶

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .

5 6 $

7 I claim exemption from withholding for 2016, and I certify that I meet both of the following conditions for exemption. • Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and

• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7 Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2016)

THIS IS A STUDENT EMPLOYEEMail form to: Student Employment Box 407810 Station BDeliver form to: 2309 West End Ave, Nashville TN 37203

JANE A. DOE 123-45-6789

Self Explanatory

Self Explanatory

0

Sign Here Leave Blank

}

Form W-4 (2016) Page 2 Deductions and Adjustments Worksheet

Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income. 1 Enter an estimate of your 2016 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state

and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1952) of your income, and miscellaneous deductions. For 2016, you may have to reduce your itemized deductions if your income is over $311,300 and you are married filing jointly or are a qualifying widow(er); $285,350 if you are head of household; $259,400 if you are single and not head of household or a qualifying widow(er); or $155,650 if you are married filing separately. See Pub. 505 for details . . . 1 $

2 Enter: { $12,600 if married filing jointly or qualifying widow(er)$9,300 if head of household $6,300 if single or married filing separately

. . . . . . . . . . . 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $ 4 Enter an estimate of your 2016 adjustments to income and any additional standard deduction (see Pub. 505) 4 $ 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2016 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $ 6 Enter an estimate of your 2016 nonwage income (such as dividends or interest) . . . . . . . . 6 $ 7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $ 8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . . 8 9 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.) Note: Use this worksheet only if the instructions under line H on page 1 direct you here. 1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 3

Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet . . . . . . . . . . 4 5 Enter the number from line 1 of this worksheet . . . . . . . . . . 5 6 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 6 7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $ 8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $ 9 Divide line 8 by the number of pay periods remaining in 2016. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2016. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck

9 $

Married Filing Jointly Table 1

All Others Married Filing Jointly Table 2

All Others

If wages from LOWEST paying job are—

Enter on line 2 above

If wages from LOWEST paying job are—

Enter on line 2 above

If wages from HIGHEST paying job are—

Enter on line 7 above

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $6,000 0 $0 - $9,000 0 $0 - $75,000 $610 $0 - $38,000 $610 6,001 - 14,000 1

14,001 - 25,000 2 25,001 - 27,000 3 27,001 - 35,000 4 35,001 - 44,000 5 44,001 - 55,000 6

9,001 - 17,001 - 26,001 - 34,001 - 44,001 - 75,001 -

17,000 1 26,000 2 34,000 3 44,000 4 75,000 5 85,000 6

75,001 - 135,000 1,010 135,001 - 205,000 1,130 205,001 - 360,000 1,340 360,001 - 405,000 1,420 405,001 and over 1,600

38,001 - 85,000 1,010 85,001 - 185,000 1,130

185,001 - 400,000 1,340 400,001 and over 1,600

55,001 - 65,000 7 65,001 - 75,000 8 75,001 - 80,000 9 80,001 - 100,000 10

100,001 - 115,000 11 115,001 - 130,000 12 130,001 - 140,000 13 140,001 - 150,000 14 150,001 and over 15

85,001 - 110,000 7 110,001 - 125,000 8 125,001 - 140,000 9 140,001 and over 10

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

F A S T S T A R T

DEPOSITDEPOSIT DIRECT INSTRUCTIONS FOR PROCESSING FEDERAL EMPLOYEE PAYMENTS

Use: For processing Federal employee net salary, allotments, and other agency - approved payments associated with Federal employment (i.e. travel reimbursement, uniform allowance, etc). Employee must complete items 1,2,3 and 5. Complete item 4 only if you want to start, cancel or change the amount of a savings or discretionary allotment - see instructions on back of form.

1. EMPLOYEE INFORMATION

TELEPHONE NUMBER (WORK)

ROUTING TRANSIT NUMBER

ACCOUNT NUMBER

ACCOUNT TITLE ________________________________________________________________ (Account Holder’s Name)

FINANCIAL INSTITUTION NAME ____________________________________________________

(Last, First, Initials)

2. TYPE OF ACCOUNT

4. ALLOTMENT INFORMATION

5. AUTHORIZATION

6. AGENCY USE:

EMPLOYEE’S SIGNATURE DATE

Complete this section only if you want to start, cancel or change the amount of a savings or discretionary allotment - see instructions on back of form.

Checking

Net Pay

Savings (whole dollar amounts only) SAVINGS START INCREASE TO:

DECREASE TO:CANCEL

CHANGE New Total $____________

Travel

Discretionary or Third Party CHECKING

Other Federal employment related payments

Savings

3. DIRECT DEPOSIT ACCOUNT INFORMATION - NET PAY/TRAVEL/OTHER (Use Sec. 4 for allotments) A voided personal check/sharedraft may be attached in lieu of completing this section. See instructions on back of this form.

TYPE OF PAYMENT

TYPE OF ALLOTMENT (Check One)

TYPE OF ACCOUNT (Check One)

ACTION (Check One)

AMOUNT (Check One)

(HOME)

Check Digit

EMPLOYEE NAME (as on payroll records)

(SSN) EMPLOYEE PAYROLL IDENTIFICATION NUMBER

ALLOTTEE’S ACCOUNT NUMBER

ALLOTTEE NAME (person/company who will receive allotment)

ALLOTTEE’S ROUTING NUMBER

Check Digit

FINANCIAL INSTITUTION NAME

ALLOTTEE’S ACCOUNT TITLE (Account Holder’s Name)

F O R M DEPARTMENT OF THE TREASURYFMS 1 1 - 9 2 2231 FINANCIAL MANAGEMENT SERVICE EDITION OF 4-90 IS OBSOLETE

1 2 3 4 5 6 7 8 9

D O E, JOHN , A

9 1 0 4 4 4 4 3 2 1

box

Check the applicable

LEAVE BLANK

ENTER FULL ROUTING/ ACCOUNTNUMBERS. IF NUMBERS EXTENDPASS SPACE PROVIDED WRITE OUTSIDE OF BLOCKS.

PRIVACY ACT STATEMENT The collection of the information you are requested to provide on this form is authorized under 31 CFR 209 and/or 210. The information is confidential and is needed to prove entitlement to payments. The information will be used to process payment data from the Federal agency to the financial institution and/or its agent.

INSTRUCTIONS FOR PROCESSING FASTSTART AUTHORIZATION

PURPOSE You may use this form to provide instructions for processing your net salary. You may also use this for to provide instructions for processing allotments and other agency - approved payments associated with your Federal employment.

1. EMPLOYEE INFORMATION (always complete this section)

2. TYPE OF ACCOUNT/PAYMENT (Put an “X” in the appropriate space to indicate a checking or savings account and type of payment.)

3. DIRECT DEPOSIT ACCOUNT INFORMATION ROUTING TRANSIT NUMBER (your financial institution’s 9-digit routing transit number) ACCOUNT NUMBER (your account number at your financial institution) ACCOUNT TITLE (the depositor’s name on the account to which payments are to be directed) FINANCIAL INSTITUTION NAME (the name of the institution to which payments are to be directed)

The Routing Transit Number (RTN) can be obtained from the financial institution or found on the bottom of a check.

1. ROUTING TRANSIT NUMBER - Here you would put “021001082”

2. ACCOUNT NUMBER - Here you would put “123-456-789”. Note the use of the dash symbol. (Include dashes where the symbol appears on the check or card.

3. ACCOUNT TITLE (must include employee

4

NAME OF DEPOSITOR STREET ADDRESS

CITY, STATE

NAME OF YOUR BANK Payable Through Another Bank

PAY TO THE ORDER OF: _______________________________________________$

101

19 ___________ _______

3

For _____________________________ ____________________________

___________________________________________________________DOLLARS

name)

5 4. FINANCIAL INSTITUTION NAME

5. If your check or sharedraft includes “payable through“ under the bank name, contact the finan­cial institution to help obtain the correct Routing

ROUTING NUMBER ACCOUNT NUMBER CHECK NUMBER Transit Number for Direct Deposit processing. 1 2

4. ALLOTMENT INFORMATION

ALLOTMENT TYPE

SAVINGS (If this option is checked, this will allow the specified allotment to be credited to an account owned by the payee.) Savings allotments are limited to two. Savings allotments must be in whole dollar amounts (no cents). The dollar amount of allotments may not exceed the pay due an employee per pay period.

DISCRETIONARY OR THIRD PARTY (If this option is checked, this will allow the specified allotment to be credited to an account not owned by the payee.) Certain restrictions may apply as to the kind of allotments your agency will allow. Check with your agency to determine what kinds of allotments it will allow. ANY CHANGES TO THE ALLOTMENT INFORMATION FURNISHED ON THIS REQUEST MUST BE MADE USING A NEW FASTSTART FORM.

TYPE OF ACCOUNT (Put an “X” in the appropriate space to indicate a checking or savings account.) ACTION (Put an “X” in the appropriate space to indicate start/cancel/change.) AMOUNT (Put an “X” in the appropriate space to indicate if an allotment is an increase, decrease and always indicate $ amount.)

ALLOTTEE’S ROUTING NUMBER: Enter person’s/company financial institution 9-digit routing transit number. ALLOTTEE’S ACCOUNT NUMBER: Enter the account number to which the allotment payment will be deposited. ALLOTTEE’S ACCOUNT NUMBER: Enter account holder’s name on the account at the financial institution. FINANCIAL INSTITUTION NAME: Enter the name of the financial institution to which the payment should be sent.

5. AUTHORIZATION Sign and date the request form after you have carefully read the instructions and Privacy Act Statement.

6. AGENCY USE (This space is reserved for agency use.)

CHANGES AND CANCELLATIONS - Contact your agency for instructions.

READ ENTIRE BRIEFING AND INITIALIN HIGHLIGHTED AREAS INDICATED BELOW. ANY QUESTIONSWILL BE ADDRESSED DURING ORIENTATION BRIEFING WITH SSGT GRAHAM.

SIGN HERELEAVE DATE BLANK