Form online 2026

1. Click ‘Get Form’ to open the Filing Status and Exemption form in our editor.
2. Begin by entering your personal information in the EMPLOYEE section. Fill in your Name, Date of Birth, Address, City/Town, State, and Zip Code as required.
3. In the FILING STATUS AND EXEMPTIONS section, select your Federal tax filing status based on your actual status at the time of injury. Ensure it matches your tax return.
4. Indicate the number of exemptions you have as of the date of injury and specify if FICA was withheld for you by selecting YES or NO.
5. Check any applicable boxes regarding age or blindness for yourself or your spouse.
6. List names, dates of birth, and relationships for all exemptions included previously.
7. If applicable, provide details about concurrent employment including employer name, address, and date of hire.
8. Finally, sign and date the form to attest that all information is correct before submitting it through our platform.

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