Complete this form so that your employer can withhold the correct California state income tax from your pay. Personal Information.To claim the exemption, the homeowner must make a one-time filing with the county assessor where the property is located. You can only apply for a Covered California exemption for tax years 2020 and later. Use Form FTB 3853 to determine if you owe an individual shared responsibility penalty or to claim exemptions from the state individual health coverage mandate. To claim exempt, write EXEMPT under line 4c. If you are eligible to claim an exemption from withholding, you can use the W-4 form. Use Worksheet B to determine whether your expected estimated deductions may entitle you to claim one or more additional withholding allowances. EXEMPTION FROM WITHHOLDING: If you wish to claim exempt, complete the federal Form W-4. EXEMPT from withholding California income tax may only be.