Temporary Worker Tax Withholding Certificate
Employee Information
Full Name
Social Security Number / Tax ID
Address
City
State
ZIP Code
Withholding Status
Filing Status
Single
Married
Head of Household
Number of Dependents
Additional Amount to Withhold (if any)
Employer Information
Employer Name
Employer Identification Number
Employer Address
Certification
I certify that the information provided on this certificate is true, correct, and complete to the best of my knowledge.
Signature
Date