ZedAI XForms QTI Example 1
From zedwiki
Example 1 (IRS Form W-4 2009)
XForms
<html xmlns="http://www.w3.org/2002/06/xhtml2/"
xmlns:xforms="http://www.w3.org/2002/xforms"
xmlns:xsd="http://www.w3.org/2001/XMLSchema"
xmlns:ev="http://www.w3.org/2001/xml-events"
xmlns:my="SYSTEM">
<head>
<title>Form W-4 Employee's Withholding Allowance Certificate (Partial)</title>
<xforms:model>
<xforms:instance>
<my:form>
<my:worksheet>
<my:itema/>
<my:itemb/>
<my:itemc/>
<my:itemd/>
<my:iteme/>
<my:itemf/>
<my:itemg/>
<my:itemh/>
</my:worksheet>
<my:q1>
<my:fname/>
<my:lname/>
<my:homeaddr/>
<my:citystatezip/>
</my:q1>
<my:q2/>
<my:q3/>
<my:q4/>
<my:q5/>
<my:q6/>
<my:q7/>
<my:q8/>
<my:q9/>
<my:q10/>
<my:declare>
<my:signature/>
<my:date/>
</my:declare>
</my:form>
</xforms:instance>
<xforms:bind nodeset="my:form/my:worksheet" relevant="false()"/>
<xforms:bind nodeset="my:form/my:q5" relevant="my:form/my:worksheet/my:itemh"
calculate="my:form/my:worksheet/my:itemh"/>
<xforms:submission action="FormW-4.xml" method="put" ref="/my:form" />
</xforms:model>
</head>
<body>
<section>
<h>Personal Allowances Worksheet (Keep for your records.)</h>
<ol>
<li>Enter "1" for yourself if no one else can claim you as a dependent
<xforms:input ref="my:form/my:worksheet/my:itema">
<xforms:label>A</xforms:label>
</xforms:input>
</li>
<li>Enter "1" if:
<ul>
<li>You are single and have only one job; or</li>
<li>You are married, have only one job, and your spouse does not
work; or</li>
<li>Your wages from a second job or your spouse's wages (or the
total of both) are $1,500 or less.</li>
</ul>
<xforms:input ref="my:form/my:worksheet/my:itemb">
<xforms:label>B</xforms:label>
</xforms:input>
</li>
<li>Enter "1" for spouse. But, you may choose to enter "-0-" if you are married
and have either a working spouse or more than one job. (Entering "-0-" may
help you avoid having too little tax withheld.)
<xforms:input ref="my:form/my:worksheet/my:itemc">
<xforms:label>C</xforms:label>
</xforms:input>
</li>
<li>Enter number of dependents (other than your spouse or yourself) you will
claim on your tax return
<xforms:input ref="my:form/my:worksheet/my:itemd">
<xforms:label>D</xforms:label>
</xforms:input>
</li>
<li>Enter "1" if you will file as head of household on your tax return (see
conditions under Head of household above)
<xforms:input ref="my:form/my:worksheet/my:iteme">
<xforms:label>E</xforms:label>
</xforms:input>
</li>
<li>Enter "1" if you have at least $1,800 of child or dependent care expenses
for which you plan to claim a credit (Note. Do not include child support
payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
<xforms:input ref="my:form/my:worksheet/my:itemf">
<xforms:label>F</xforms:label>
</xforms:input>
</li>
<li>Child Tax Credit (including additional child tax credit). See Pub. 972,
Child Tax Credit, for more information.
<ul>
<li>If your total income will be less than $61,000 ($90,000 if married),
enter "2" for each eligible child; then less "1" if you have
three or more eligible children.</li>
<li>If your total income will be between $61,000 and $84,000 ($90,000
and $119,000 if married), enter "1" for each eligible child
plus "1" additional if you have six or more eligible children.</li>
</ul>
<xforms:input ref="my:form/my:worksheet/my:itemg">
<xforms:label>G</xforms:label>
</xforms:input>
</li>
<li>
<p>Add lines A through G and enter total here. (Note. This may be different
from the number of exemptions you claim on your tax return.)</p>
<p>For accuracy, complete all worksheets that apply.</p>
<ul>
<li>If you plan to itemize or claim adjustments to income and want to
reduce your withholding, see the Deductions and Adjustments
Worksheet on page 2.</li>
<li>If you have more than one job or are married and you and your spouse
both work and the combined earnings from all jobs exceed $40,000
($25,000 if married), see the Two-Earners/Multiple Jobs Worksheet
on page 2 to avoid having too little tax withheld.</li>
<li>If neither of the above situations applies, stop here and enter the
number from line H on line 5 of Form W-4 below.</li>
</ul>
<xforms:input ref="my:form/my:worksheet/my:itemh">
<xforms:label>H</xforms:label>
</xforms:input>
</li>
</ol>
</section>
<section>
<h>Form W-4 Employee's Withholding Allowance Certificate 2009</h>
<p>CMB No. 1545-0074</p>
<p>Department of the Treasury</p>
<p>Internal Revenue Service</p>
<p>Whether you are entitled to claim a certain number of allowances or exemption from
withholding is subject to review by the IRS. Your employer may be required to send a
copy of this form to the IRS.</p>
<ol>
<li>
<xforms:input ref="my:form/my:q1/my:fname">
<xforms:label>Type or print your first name and middle initial.</xforms:label>
</xforms:input>
<xforms:input ref="my:form/my:q1/my:lname">
<xforms:label>Last name</xforms:label>
</xforms:input>
<xforms:input ref="my:form/my:q1/my:homeaddr">
<xforms:label>Home address (number and street or rural route)</xforms:label>
</xforms:input>
<xforms:input ref="my:form/my:q1/my:citystatezip">
<xforms:label>City or town, state, and ZIP code</xforms:label>
</xforms:input>
</li>
<li>
<xforms:input ref="my:form/my:q2">
<xforms:label>Your social security number</xforms:label>
</xforms:input>
</li>
<li>
<xforms:select1 ref="my:form/my:q3">
<xforms:label>Marital status</xforms:label>
<xforms:item>
<xforms:label>Single</xforms:label>
<xforms:value>single</xforms:value>
</xforms:item>
<xforms:item>
<xforms:label>Married</xforms:label>
<xforms:value>married</xforms:value>
</xforms:item>
<xforms:item>
<xforms:label>Married, but withhold at higher Single rate.</xforms:label>
<xforms:value>marriedexception</xforms:value>
</xforms:item>
</xforms:select1>
Note. If married, but legally separated, or spouse is a nonresident alien, check
the "Single" box.
</li>
<li>
<xforms:input ref="my:form/my:q5">
<xforms:label>Total number of allowances you are claiming (from line
H above or from the applicable worksheet on page 2)</xforms:label>
</xforms:input>
</li>
<li>
<xforms:input ref="my:form/my:q6">
<xforms:label>Additional amount, if any, you want withheld from each
paycheck</xforms:label>
</xforms:input>
</li>
<li>I claim exemption from withholding for 2009, and I certify that I meet both of the
following conditions for exemption.
<ul>
<li>Last year I had a right to a refund of all federal income tax withheld
because4 I had no tax liability and</li>
<li>This year I expect a refund of all federal income tax withheld because
I expect to have no tax liability.</li>
</ul>
<xforms:input ref="my:form/my:q7">
<xforms:label>If you meet both conditions, write "Exempt" here</xforms:label>
</xforms:input>
</li>
</ol>
<p>Under penalties of perjury, I declare that I have examined this certificate and to the best
of my knowledge and belief, it is true, correct, and complete.</p>
<p>
<xforms:input ref="my:form/my:declare/my:signature">
<xforms:label>Employee's signature (Form is not valid unless you sign it.)</xforms:label>
</xforms:input>
<xforms:input ref="my:form/my:declare/my:date">
<xforms:label>Date</xforms:label>
</xforms:input>
</p>
<p>(Employer: Complete lines 8 and 10 only if sending to the IRS.)</p>
<ol>
<li>
<xforms:input ref="my:form/my:q8">
<xforms:label>Employer's name and address</xforms:label>
</xforms:input>
</li>
<li>
<xforms:input ref="my:form/my:q9">
<xforms:label>Office code (optional)</xforms:label>
</xforms:input>
</li>
<li>
<xforms:input ref="my:form/my:q10">
<xforms:label>Employer identification number (EIN)</xforms:label>
</xforms:input>
</li>
</ol>
</section>
</body>
</html>
QTI
<html xmlns="http://www.w3.org/2002/06/xhtml2/"
xmlns:qti="http://www.imsglobal.org/xsd/imsqti_v2p0"
xmlns:xsd="http://www.w3.org/2001/XMLSchema"
xmlns:ev="http://www.w3.org/2001/xml-events"
xmlns:my="SYSTEM">
<head>
<title>Form W-4 Employee's Withholding Allowance Certificate (Partial)</title>
</head>
<body>
<section>
<h>Personal Allowances Worksheet (Keep for your records.)</h>
<ol>
<li>
<qti:assessmentItem identifier="textEntry" title="Worksheet Item A"
adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="worksheeta"
cardinality="single"/>
<qti:itemBody>
<qti:p>Enter "1" for yourself if no one else can claim you
as a dependent
<qti:textEntryInteraction responseIdentifier="worksheeta"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
<li>
<qti:assessmentItem identifier="textEntry" title="Worksheet Item B"
adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="worksheetb"
cardinality="single"/>
<qti:itemBody>
<qti:p>Enter "1" if:</qti:p>
<qti:ul>
<qti:li>You are single and have only one job; or</qti:li>
<qti:li>You are married, have only one job, and your spouse
does not work; or</qti:li>
<qti:li>Your wages from a second job or your spouse's wages
(or the total of both) are $1,500 or less.</qti:li>
</qti:ul>
<qti:p>
<qti:textEntryInteraction responseIdentifier="worksheetb"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
<li>
<qti:assessmentItem identifier="textEntry" title="Worksheet Item C"
adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="worksheetc"
cardinality="single"/>
<qti:itemBody>
<qti:p>Enter "1" for spouse. But, you may choose to enter
"-0-" if you are married and have either a working
spouse or more than one job. (Entering "-0-" may help you
avoid having too little tax withheld.)
<qti:textEntryInteraction responseIdentifier="worksheetc"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
<li>
<qti:assessmentItem identifier="textEntry" title="Worksheet Item D"
adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="worksheetd"
cardinality="single"/>
<qti:itemBody>
<qti:p>Enter number of dependents (other than your spouse or
yourself) you will claim on your tax return
<qti:textEntryInteraction responseIdentifier="worksheetd"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
<li>
<qti:assessmentItem identifier="textEntry" title="Worksheet Item E"
adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="worksheete"
cardinality="single"/>
<qti:itemBody>
<qti:p>Enter "1" if you will file as head of household on
your tax return (see conditions under Head of household above)
<qti:textEntryInteraction responseIdentifier="worksheete"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
<li>
<qti:assessmentItem identifier="textEntry" title="Worksheet Item F"
adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="worksheetf"
cardinality="single"/>
<qti:itemBody>
<qti:p>Enter "1" if you have at least $1,800 of child or dependent
care expenses for which you plan to claim a credit (Note. Do
not include child support payments. See Pub. 503, Child and
Dependent Care Expenses, for details.)
<qti:textEntryInteraction responseIdentifier="worksheetf"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
<li>
<qti:assessmentItem identifier="textEntry" title="Worksheet Item G"
adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="worksheetg"
cardinality="single"/>
<qti:itemBody>
<qti:p>Child Tax Credit (including additional child tax credit).
See Pub. 972, Child Tax Credit, for more information.</qti:p>
<qti:ul>
<qti:li>If your total income will be less than $61,000 ($90,000
if married), enter "2" for each eligible child; then less
"1" if you have three or more eligible children.</qti:li>
<qti:li>If your total income will be between $61,000 and $84,000
($90,000 and $119,000 if married), enter "1" for each
eligible child plus "1" additional if you have six or more
eligible children.</qti:li>
</qti:ul>
<qti:p>
<qti:textEntryInteraction responseIdentifier="worksheetg"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
<li>
<qti:assessmentItem identifier="textEntry" title="Worksheet Item H"
adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="worksheeth"
cardinality="single"/>
<qti:itemBody>
<qti:p>Add lines A through G and enter total here. (Note. This may be
different from the number of exemptions you claim on your tax
return.)</qti:p>
<qti:p>For accuracy, complete all worksheets that apply.</qti:p>
<qti:ul>
<qti:li>If you plan to itemize or claim adjustments to income and
want to reduce your withholding, see the Deductions and
Adjustments Worksheet on page 2.</qti:li>
<qti:li>If you have more than one job or are married and you and
your spouse both work and the combined earnings from all jobs
exceed $40,000 ($25,000 if married), see the Two-Earners/Multiple
Jobs Worksheet on page 2 to avoid having too little tax
withheld.</qti:li>
<qti:li>If neither of the above situations applies, stop here and
enter the number from line H on line 5 of Form W-4
below.</qti:li>
</qti:ul>
<qti:p>
<qti:textEntryInteraction responseIdentifier="worksheeth"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
</ol>
</section>
<section>
<h>Form W-4 Employee's Withholding Allowance Certificate 2009</h>
<p>CMB No. 1545-0074</p>
<p>Department of the Treasury</p>
<p>Internal Revenue Service</p>
<p>Whether you are entitled to claim a certain number of allowances or exemption from
withholding is subject to review by the IRS. Your employer may be required to send a
copy of this form to the IRS.</p>
<ol>
<li>
<qti:assessmentItem identifier="textEntry" title="Question 1"
adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="q1fname" cardinality="single"/>
<qti:responseDeclaration identifier="q1lname" cardinality="single"/>
<qti:responseDeclaration identifier="q1homeaddr" cardinality="single"/>
<qti:responseDeclaration identifier="q1citystatezip" cardinality="single"/>
<qti:itemBody>
<qti:p>Type or print your first name and middle initial.
<qti:textEntryInteraction responseIdentifier="q1fname"/>
</qti:p>
<qti:p>Last name
<qti:textEntryInteraction responseIdentifier="q1lname"/>
</qti:p>
<qti:p>Home address (number and street or rural route)
<qti:textEntryInteraction responseIdentifier="q1homeaddr"/>
</qti:p>
<qti:p>City or town, state, and ZIP code
<qti:textEntryInteraction responseIdentifier="q1citystatezip"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
<li>
<qti:assessmentItem identifier="textEntry" title="Question 2"
adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="q2" cardinality="single"/>
<qti:itemBody>
<qti:p>Your social security number
<qti:textEntryInteraction responseIdentifier="q2"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
<li>
<qti:assessmentItem identifier="choice" title="Question 3" adaptive="false"
timeDependent="false">
<qti:responseDeclaration identifier="q3" cardinality="single"/>
<qti:itemBody>
<qti:choiceInteraction responseIdentifier="q3" shuffle="false"
maxChoices="1">
<qti:simpleChoice identifier="single">Single
</qti:simpleChoice>
<qti:simpleChoice identifier="married">Married
</qti:simpleChoice>
<qti:simpleChoice identifier="marriedexception">
Married, but withhold at higher Single rate.
</qti:simpleChoice>
</qti:choiceInteraction>
<qti:p>Note. If married, but legally separated, or spouse is a
nonresident alien, check the "Single" box.</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
<li>
<qti:assessmentItem identifier="textEntry" title="Question 5"
adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="q5" cardinality="single"/>
<qti:itemBody>
<qti:p>Total number of allowances you are claiming (from line
H above or from the applicable worksheet on page 2)
<qti:textEntryInteraction responseIdentifier="q5"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
<li>
<qti:assessmentItem identifier="textEntry" title="Question 6"
adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="q6" cardinality="single"/>
<qti:itemBody>
<qti:p>Additional amount, if any, you want withheld from each
paycheck <qti:textEntryInteraction responseIdentifier="q6"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
<li>
<qti:assessmentItem identifier="textEntry" title="Question 7"
adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="q7" cardinality="single"/>
<qti:itemBody>
<qti:p>I claim exemption from withholding for 2009, and I certify
that I meet both of the following conditions for exemption.
</qti:p>
<qti:ul>
<qti:li>Last year I had a right to a refund of all federal
income tax withheld because I had no tax liability and
</qti:li>
<qti:li>This year I expect a refund of all federal income tax
withheld because I expect to have no tax liability.</qti:li>
</qti:ul>
<qti:p>If you meet both conditions, write "Exempt" here
<qti:textEntryInteraction responseIdentifier="q7"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
</ol>
<p>Under penalties of perjury, I declare that I have examined this certificate and to the best
of my knowledge and belief, it is true, correct, and complete.</p>
<qti:assessmentItem identifier="textEntry" title="Name" adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="name" cardinality="single"/>
<qti:itemBody>
<qti:p>Employee's signature (Form is not valid unless you sign it.)
<qti:textEntryInteraction responseIdentifier="name"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
<qti:assessmentItem identifier="textEntry" title="Date" adaptive="false" timeDependent="false">
<qti:responseDeclaration identifier="date" cardinality="single"/>
<qti:itemBody>
<qti:p>Date <qti:textEntryInteraction responseIdentifier="date"/></qti:p>
</qti:itemBody>
</qti:assessmentItem>
<p>(Employer: Complete lines 8 and 10 only if sending to the IRS.)</p>
<ol>
<li>
<qti:assessmentItem identifier="textEntry" title="Question 8" adaptive="false"
timeDependent="false">
<qti:responseDeclaration identifier="q8" cardinality="single"/>
<qti:itemBody>
<qti:p>Employer's name and address
<qti:textEntryInteraction responseIdentifier="q8"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
<li>
<qti:assessmentItem identifier="textEntry" title="Question 9" adaptive="false"
timeDependent="false">
<qti:responseDeclaration identifier="q9" cardinality="single"/>
<qti:itemBody>
<qti:p>Office code (optional)
<qti:textEntryInteraction responseIdentifier="q9"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
<li>
<qti:assessmentItem identifier="textEntry" title="Question 10" adaptive="false"
timeDependent="false">
<qti:responseDeclaration identifier="q10" cardinality="single"/>
<qti:itemBody>
<qti:p>Employer identification number (EIN)
<qti:textEntryInteraction responseIdentifier="q10"/>
</qti:p>
</qti:itemBody>
</qti:assessmentItem>
</li>
</ol>
</section>
</body>
</html>
