Department of the Treasury - Internal Revenue Service

Date

Form 6450

(Rev. March 1992)

Questionnaire To Determine Exemption From Withholding

Your name

Your Social Security Number (as shown on the letter)

If your name or social security number (SSN) is incorrect on the letter, or an asterisk (*) appears after the SSN, show your correct SSN and any former names in the boxes below.

Your correct social security number

Phone number and best time to call

Former name(s) (Please print)

INSTRUCTIONS:

If you are claiming exempt status, please complete Part 1 of this form.
If you can be claimed as a dependent on another person's income tax return, complete Part II; If you are claiming exemption from withholding based on a vow of poverty, complete Part III;

If you had income earned abroad, complete Part IV.

ALL must complete the enclosed W-4 including the appropriate worksheet(s) and return both forms in the enclosed envelope. (DO NOT DETACH CERTIFICATE)

Part 1 - Qualifications for Claiming Exemption from Withholding

1. Last year, I had a right to a refund of ALL income tax withheld because I did

not have any Federal income tax liability

Yes

No

2. This year, I expect to have a right to a refund of ALL income tax withheld

because I do not expect to have any Federal income tax liability

Yes

No

3. Are you a resident alien?

Yes

No

4. If yes, give Visa Type

Date arrived in U.S.

Country

(Visa types F, J or M may not claim exempt status if compensation is received for personal services performed in

the U.S)

Part II - For Individuals Who Can Be Claimed on Another Person's Tax Return

5. Could you be claimed as dependent on another person's

tax return last year?

Yes

No

This year?

Yes

No

6. What was the total amount of your earned income last year?

(Earned income is income from wages, salaries, professional fees, tips, and other compensation received for personal services you performed. It also includes any amount received as a scholarship that you must include in your

income.)

$

7. What you do estimate your total earned income will be this year?

$

8. What was the total amount of you unearned income last year?

(Unearned income is all income other than salaries, wages, tips, and personal service income. It includes interest, dividends, alimony, capital gains and losses,

pensions)

$

9. What do you estimate your total unearned income will be this year?

$

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A

Cat. No 24504D

Form 6450 (Rev. 3-92)

Part III - Claiming Exemption from Withholding Based on a Vow of Poverty

10. Are you a minister of a church?

Yes

No

11. Are you a member of a religious order?

Yes

No

12. Enter the name and address of the church or order

Yes

No

Name

Street Address

City, State, Zip

13. Did you have any salary or wages last year from ouside the church or order?

Yes

No

If yes, show the names of your outside employers and how much you expect to earn this year from employment outside the church or order.

Part IV - Foreign Issues

14. Are you eligible for the foreign earned income exclusion this year?

Yes

No

15. If yes, enter the amount here (not to exceed $70,000)

$

Also enter any housing exclusion deduction you are entitled to

$

Certification

Under penalties of perjury of the laws of these United States of America, I declare that I have examined this questionnaire and, to the best of my knowledge and belief, it is true, correct, and complete.

Your signature

Date

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Employer Name	Estimated Earnings This Year	

		

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