Appendix X Certificate of Exemption from Withholding Page X - 1 of 4 The Federal Zone: Reader's Notes: Page X - 2 of 4 Appendix X CERTIFICATE OF EXEMPTION FROM WITHHOLDING IN LIEU OF W-4 Consistent with Section 3402(n) of the Internal Revenue Code, shown herewith, I certify to being EXEMPT by law from all federal income tax withholdings because: A. No liability for income tax has knowingly been incurred by me under Subtitle A in the past year or in previous years. B. No liability for income tax will knowingly be incurred by me under Subtitle A in the current year or in future years. Effective immediately, stop all federal tax withholdings. Thank you for your consideration. With Explicit Reservation of All My Unalienable Rights and Without Prejudice to Any of My Unalienable Rights Signed: _________________________________________________________ Name: ___________________________________________________________ Address: ________________________________________________________ County of: ______________________________________________________ State of: _______________________________________________________ Acknowledgement CALIFORNIA STATE/REPUBLIC ) ) Subscribed, Sworn and Sealed MARIN COUNTY ) On this ______ day of ______________________________, 1992, _________________________________________________________________ did personally appear before me, and is known to be the one described in, and who executed the foregoing instrument, and acknowledged that he executed the same as his free act and deed as a Citizen/Sovereign in this above named said State of the Union. Purpose of notary is for identification only, and not for granting jurisdiction to any government agency. _____________________________________ Notary Public Page X - 3 of 4 The Federal Zone: Internal Revenue Code, Section 3402(n): (n) Employees Incurring No Income Tax Liability. -- Notwithstanding any other provision of this section, an employer shall not be required to deduct and withhold any tax under this chapter upon a payment of wages to an employee if there is in effect with respect to such payment a withholding exemption certificate (in such form and containing such other information as the Secretary may prescribe) furnished to the employer by the employee certifying that the employee -- (1) incurred no liability for income tax imposed under Subtitle A for his preceding taxable year, and (2) anticipates that he will incur no liability for income tax imposed under Subtitle A for his current taxable year. The Secretary shall by regulations provide for the coordination of the provisions of this subsection with the provisions of subsection (f). [26 USC 3402(n)] Page X - 4 of 4