Agricultural Worker Tax Withholding Certificate
Employee Information
Full Name
Social Security Number
Address
City
State
ZIP Code
Employer Information
Employer Name
Employer TIN
Employer Address
City
State
ZIP Code
Tax Withholding Details
Effective Date
Number of Exemptions
Filing Status
Single
Married
Head of Household
Other Information
Certification
I certify that the information given on this certificate is true and correct to the best of my knowledge.
Employee Signature
Date