GUIDELINES FOR STATE WITHHOLDING FORMS
State
AL
AZ
AR
CA
CT
DC
GA
HI
IL
IN
IA
KY
LA
ME
MD
MA
MI
Form Name
A-4
A-4
AR4EC
DE 4
CT-W4
D-4
G-4
HW-4
IL-W-4
WH-4
IA W4
K-4
R-1300 (L-4)
W-4ME
MW 507
M-4
MI-W4
Accepts Federal Form
No
No
Yes
Yes
No
No
Yes
No
No
No
No
No
No
No
No
Yes
No
MN
MS
MO
NJ
NY
NC
W-4MN
89-350
MO W4
NJ-W4
IT-2104
NC-4
Yes
No
No
Yes
Yes
No
OH
PR
VT
VA
WV
WI
IT-4
499 R-4.1
W-4VT
VA-4
WV/IT-104
WT-4
No
No
Yes
No
Yes
Yes
PA
Residency Certification Form
No
IN
Certificate of Residency
No
Notes - All states that do not accept the Federal W-4 form must have a state specific
form for all new hires
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required when claiming fewer exemptions than Federal W-4, Claim more than 10 MN
withholding allowances, want additional MN withholding deducted per pay period
Required each time you change the number of allowances
Required each time you change the number of allowances
Required for all NYC and Yonkers residents
Required each time you change the number of allowances
Required each time you change the number of allowances and each time you move and
change school districts
Required each time you change the number of allowances
Required each time you change the number of allowances
Required for every address change
Required for employees that live in states with Reciprocity with IN that work in IN (KY,
MI, OH, PA, WI)
THIS FORM MAY BE REPRODUCED.
Employee: Complete Form A-4 and file it with your employer. Otherwise, tax will be withheld without exemption.
CHANGES IN EXEMPTIONS: You may file a new certificate at any time if the number of
your exemptions INCREASE. You must file a new certificate within 10 days if the number
of exemptions previously claimed by you DECREASES for any of the following reasons:
Employer: Keep this certificate on file. If an employee is believed to have claimed more
exemptions than that which they are legally entitled to claim, the Department should be
notified. Any correspondence concerning this form should be sent to the AL Dept of Revenue, Withholding Tax Section, PO Box 327480, Montgomery, AL 36132-7480 or by fax to
334-242-0112. Please include contact information with your correspondence.
(a) Your spouse for whom you have been claiming exemption is divorced, legally separated, or claims her or his own exemption on a separate certificate.
(b) You no longer provide more than half of the support for someone you previously claimed
a dependent exemption for.
Penalties: Section 40-18-73, Code of Alabama 1975. Every employee, on or before the
date of commencement of employment, shall furnish his or her employer with a signed Alabama withholding exemption certificate relating to the number of withholding exemptions
which he or she claims, which in no event shall exceed the number to which the employee
is entitled. In the event the employee inflates the number of exemptions allowed by this
Chapter on Form A-4, the employee shall pay a penalty of five hundred dollars ($500) for
such action pursuant to Section 40-29-75.
DECREASES in exemption, such as the death of a spouse or dependent, will not require
the filing of a new exemption certificate until the following year.
DEPENDENTS: To qualify as your dependent (Line 4 on other side), a person must receive
more than one-half of his or her support from you for the year and must be related to you
as follows:
Your son or daughter (including legally adopted children), grandchild, stepson, stepdaughter, son-in-law, or daughter-in-law;
Exempt Status: Military Spouses Residency Relief Act. This exemption applies to a
spouse of a US Armed Service member who is present in Alabama in compliance with military orders and who maintains domicile in another state. Employee should provide their employer with valid military identification and a copy of a current leave and earnings statement
or Form DD-2058. Complete line 6 on front of Form A-4 if you qualify for this exemption.
Your father, mother, grandparent, stepfather, stepmother, father-in-law, or mother-in-law;
Your brother, sister, stepbrother, stepsister, half brother, half sister, brother-in-law, or sisterin-law;
Your uncle, aunt, nephew, or niece (but only if related by blood).
Exempt Status: No tax liability. An exemption from withholding may be claimed if you filed
an Alabama income tax return in the prior year, had a zero tax liability on that return, and
you anticipate a zero tax liability on your current year return. If you had any tax withheld in
the prior year and did not receive a full refund of that amount, you will not qualify and should
complete the front of Form A-4.
PLEASE CUT HERE
FORM
A-4
ALABAMA DEPARTMENT OF REVENUE
REV. 11/10
EMPLOYEE’S FULL NAME
HOME ADDRESS
Reset Form
Employee’s Withholding Exemption Certificate
SOCIAL SECURITY NO.
CITY
STATE
ZIP CODE
SIGNED
DATE
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. See reverse side for penalty details.
HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS
1. If you claim no personal exemption for yourself and wish to withhold at the highest rate, write the figure “0”, sign and date Form A-4 and file it with your employer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. If you are SINGLE or MARRIED FILING SEPARATELY, a $1,500 personal exemption is allowed. Write the letter “S” if claiming the SINGLE exemption or
“MS” if claiming the MARRIED FILING SEPARATELY exemption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. If you are MARRIED or SINGLE CLAIMING HEAD OF FAMILY, a $3,000 personal exemption is allowed. Write the letter “M” if you are claiming an exemption for both yourself and
your spouse or “H” if you are single with qualifying dependents and are claiming the HEAD OF FAMILY exemption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Number of dependents (other than spouse) that you will provide more than one-half of the support for during the year. See instructions for dependent qualifications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Additional amount, if any, you want deducted each pay period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. Exempt Status: If you meet the conditions set forth under the Military Spouses Residency Relief Act and will have no Alabama income tax liability, skip lines 1-5, write “EXEMPT” on
line 6, sign and date Form A-4 and file it with your employer. See instructions on the back of Form A-4 for the documentation you must provide to your employer in order to qualify. . . . . . . . . . . . . . . . .
7. Exempt Status: If you had no Alabama income tax liability last year and you anticipate no Alabama income tax liability this year, you may claim an exemption from Alabama
withholding tax. Skip lines 1-6, write “EXEMPT” on line 7, sign and date Form A-4 and file it with your employer. See instructions on the back of Form A-4 to be sure you qualify. . . . . . . . . . . . . . . . . . . .
LINE 8 BELOW TO BE COMPLETED BY YOUR EMPLOYER
8. TOTAL EXEMPTIONS (Example: Employee claims “M” on line 3 and 2 on line 4. Employer should use column headed M-2 in the Withholding Tax Tables and Instructions for Employers.) . . . . . . . . . .
EMPLOYER NAME
EMPLOYER FEIN
EMPLOYER STATE ID
$
AR4EC
STATE OF ARKANSAS
Employee’s Withholding Exemption Certificate
Print Full Name_ ________________________________________________ Social Security Number_____________________________________
Print Home Address______________________________________________ City______________________________State_ _____ Zip__________
How to Claim Your Withholding
Employee:
File this form with
your employer.
Otherwise, your
employer must
withhold state
income tax from
your wages without
exemptions or
dependents.
Employer:
Keep this certificate
with your records.
See instructions below
Number of Exemptions
Claimed
1. CHECK ONE OF THE FOLLOWING FOR EXEMPTIONS CLAIMED
a.
You claim yourself. (Enter one exemption).......................................................................1a
b.
You claim yourself and your spouse. (Enter two exemptions)..........................................1b
c.
Head of Household, and you claim yourself. (Enter two exemptions)..............................1c
2. NUMBER OF CHILDREN or DEPENDENTS. (Enter one exemption per dependent).................. 2
3. TOTAL EXEMPTIONS. (Add Lines 1a, b, c, and 2)
If no exemptions or dependents are claimed, enter zero............................................................... 3
4. Additional amount, if any, you want deducted from each paycheck. (Enter dollar amount).......... 4
5. I qualify for the low income tax rates. (See below for details)........................................................ 5 Please check filing status:
Single
Married Filing Jointly
Head of Household
Yes
No
I certify that the number of exemptions and dependents claimed on this certificate does not exceed the number to which I am entitled.
Signature:_______________________________________________________________________________________Date:__________________ Instructions
TYPES OF INCOME - This form can be used for withholding on all types
of income, including pensions and annuities.
NUMBER OF EXEMPTIONS – (Husband and/or Wife) Do not claim more
than the correct number of exemptions. However, if you expect to owe more
income tax for the year, you may increase your withholding by claiming a
smaller number of exemptions and/or dependents, or you may enter into an
agreement with your employer to have additional amounts withheld. This is
especially important if you have more than one employer, or if both husband
and wife are employed.
DEPENDENTS – To qualify as your dependent (line 2 of form), a person
must (a) receive more than 1/2 of their support from you for the year, (b)
not be claimed as a dependent by such person’s spouse, (c) be a citizen
or resident of the United States, and (d) have your home as their principal
residence and be a member of your household for the entire year or be
related to you as follows: son, daughter, grandchild, stepson, stepdaughter,
son-in-law or daughter-in-law; your father, mother, grandparent, stepfather,
stepmother, father-in-law or mother-in-law; your brother, sister, stepbrother,
stepsister, half brother, half sister, brother-in-law or sister-in-law; your uncle,
aunt, nephew or niece (but only if related by blood).
CHANGES IN EXEMPTIONS OR DEPENDENTS – You may file
a new certificate at any time if the number of exemptions or dependents
INCREASES. You must file a new certificate within 10 days if the number
of exemptions or dependents previously claimed by you DECREASES for
any of the following reasons:
AR4EC (R 12/29/14)
(a) Your spouse for whom you have been claiming an exemption is divorced or legally separated from you, or claims
his or her own exemption on a separate certificate, or
(b) The support you provide to a dependent for whom you claimed
an exemption is expected to be less than half of the total support for the year.
OTHER DECREASES in exemptions or dependents, such as the death of a
spouse or a dependent, does not affect your withholding until next year, but
requires the filing of a new certificate by December 1 of the year in which
they occur.
You may claim additional amounts of withholding tax if desired. This will
apply most often when you have income other than wages.
You qualify for the low income tax rates if your total income from all
sources is:
(a) Single
$11,591 to $15,200
(b) Married Filing Jointly
$19,547 to $24,400
1 or less dependents)
(c) Married Filing Jointly
$23,525 to $30,400
(2 or more dependents)
(d) Head of Household/Qualifying Widow(er) $16,479 to $21,400
(e) Head of Household/Qualifying Widow(er) $19,644 to $24,200
(2 or more dependents)
For additional information consult your employer or write to:
Arkansas Withholding Tax Section
P. O. Box 8055
Little Rock, Arkansas 72203-8055
Arizona Form
A-4
2016
Employee’s Arizona Withholding Election
Type or print your Full Name
Your Social Security Number
Home Address – number and street or rural route
City or Town
State
ZIP Code
Choose either box 1 or box 2:
 1 Withhold from gross taxable wages at the percentage checked (check only one percentage):
 0.8%
 1.3%
 1.8%
 2.7%
 3.6%
 4.2%
  Check this box and enter an extra amount to be withheld from each paycheck ................
 5.1%
$
 2 I elect an Arizona withholding percentage of zero, and I certify that I expect to have
no Arizona tax liability for the current taxable year.
Print
I certify that I have made the election marked above.
SIGNATURE
DATE
Employee’s Instructions
Arizona law requires your employer to withhold Arizona income
tax from your wages for work done in Arizona. This amount
is applied to your Arizona income tax due when you file your
tax return. The amount withheld is a percentage of your gross
taxable wages of every paycheck. You may also have your
employer withhold an extra amount from each paycheck.
Complete this form to select a percentage and any extra
amount to be withheld from each paycheck.
What are my “Gross Taxable Wages”?
For withholding purposes, your “gross taxable wages” are the
wages that will generally be in box 1 of your federal Form W-2.
It is your gross wages less any pretax deductions, such as your
share of health insurance premiums.
New Employees
Complete this form in the first five days of employment to select
an Arizona withholding percentage. You may also have your
employer withhold an extra amount from each paycheck. If you
do not file this form, the department requires your employer to
withhold 2.7% of your gross taxable wages.
Current Employees
If you want to change the current amount withheld, you must
file this form to change the Arizona withholding percentage or
change the extra amount withheld.
What Should I do With Form A-4?
Give your completed Form A-4 to your employer.
ADOR 10121 (15)
Electing a Withholding Percentage of Zero
You may elect an Arizona withholding percentage of zero
if you expect to have no Arizona income tax liability for the
current year. Arizona tax liability is gross tax liability less any
tax credits, such as the family tax credit, school tax credits, or
credits for taxes paid to other states. If you make this election,
your employer will not withhold Arizona income tax from your
wages for payroll periods beginning after the date you file
the form. Zero withholding does not relieve you from paying
Arizona income taxes that might be due at the time you file
your Arizona income tax return. If you have an Arizona tax
liability when you file your return or if at any time during the
current year conditions change so that you expect to have a tax
liability, you should promptly file a new Form A-4 and choose a
percentage that applies to you.
Voluntary Withholding Election by Certain
Nonresident Employees
Compensation earned by nonresidents while physically working
in Arizona for temporary periods is subject to Arizona income
tax. However, under Arizona law, compensation paid to certain
nonresident employees is not subject to Arizona income tax
withholding. These nonresident employees need to review
their situations and determine whether they should elect to
have Arizona income taxes withheld from their Arizona source
compensation. Nonresident employees may request that their
employer withhold Arizona income taxes by completing this
form to elect Arizona income tax withholding.
This form can be used to manually compute your
withholding allowances, or you can electronically
compute them at www.taxes.ca.gov/de4.pdf.
EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE
Type or Print Your Full Name
Your Social Security Number
Home Address (Number and Street or Rural Route)
Filing Status Withholding Allowances
 SINGLE or MARRIED (with two or more incomes)
MARRIED (one income)
HEAD OF HOUSEHOLD
City, State, and ZIP Code
1. Number of allowances for Regular Withholding Allowances, Worksheet A
Number of allowances from the Estimated Deductions, Worksheet B
Total Number of Allowances (A + B) when using the California
Withholding Schedules for 2015
OR
2. Additional amount of state income tax to be withheld each pay period (if employer agrees), Worksheet C
OR
3. I certify under penalty of perjury that I am not subject to California withholding. I meet the conditions set forth under
the Service Member Civil Relief Act, as amended by the Military Spouses Residency Relief Act.
(Check box here)

Under the penalties of perjury, I certify that the number of withholding allowances claimed on this certificate does not exceed the
number to which I am entitled or, if claiming exemption from withholding, that I am entitled to claim the exempt status.
Signature
Date
Employer’s Name and Address
California Employer Account Number
cut here
Give the top portion of this page to your employer and keep the remainder for your records.
YOUR CALIFORNIA PERSONAL INCOME TAX MAY BE UNDERWITHHELD IF YOU DO NOT FILE THIS DE 4 FORM.
IF YOU RELY ON THE FEDERAL FORM W-4 FOR YOUR CALIFORNIA WITHHOLDING ALLOWANCES, YOUR CALIFORNIA STATE
PERSONAL INCOME TAX MAY BE UNDERWITHHELD AND YOU MAY OWE MONEY AT THE END OF THE YEAR.
PURPOSE: This certificate, DE 4, is for California Personal Income
Tax (PIT) withholding purposes only. The DE 4 is used to compute
the amount of taxes to be withheld from your wages, by your
employer, to accurately reflect your state tax withholding obligation.
You should complete this form if either:
(1) You claim a different marital status, number of regular allowances,
or different additional dollar amount to be withheld for California PIT
withholding than you claim for federal income tax withholding or,
(2) You claim additional allowances for estimated deductions.
THIS FORM WILL NOT CHANGE YOUR FEDERAL
WITHHOLDING ALLOWANCES.
The federal Form W-4 is applicable for California withholding
purposes if you wish to claim the same marital status, number
of regular allowances, and/or the same additional dollar amount
to be withheld for state and federal purposes. However, federal
tax brackets and withholding methods do not reflect state PIT
withholding tables. If you rely on the number of withholding
allowances you claim on your Form W-4 withholding allowance
certificate for your state income tax withholding, you may
be significantly underwithheld. This is particularly true if your
household income is derived from more than one source.
CHECK YOUR WITHHOLDING: After your Form W-4
and/or DE 4 takes effect, compare the state income tax withheld
with your estimated total annual tax. For state withholding, use
the worksheets on this form.
EXEMPTION FROM WITHHOLDING: If you wish to claim
exempt, complete the federal Form W-4. You may claim exempt
from withholding California income tax if you did not owe any
federal income tax last year and you do not expect to owe any
federal income tax this year. The exemption is good for one year.
If you continue to qualify for the exempt filing status, a new
Form W-4 designating EXEMPT must be submitted by February
15 each year to continue your exemption. If you are not having
federal income tax withheld this year but expect to have a tax
liability next year, you are reuired to give your employer a new
Form W-4 by December 1.
DE 4 Rev. 43 (1-15)
DE 4 Rev. 43 (1-15) (INTERNET)
Page 1 of 4
CU
CU
EXEMPTION FROM WITHHOLDING (continued): Under the Service Member Civil Relief Act, as amended by the Military Spouses
Residency Relief Act, you may be exempt from California income tax on your wages if (i) your spouse is a member of the armed forces
present in California in compliance with military orders; (ii) you are present in California solely to be with your spouse; and (iii) you
maintain your domicile in another state. If you claim exemption under this act, check the box on Line 3. You may be required to provide
proof of exemption upon request.
IF YOU NEED MORE DETAILED INFORMATION, SEE THE INSTRUCTIONS THAT CAME WITH YOUR LAST CALIFORNIA
INCOME TAX RETURN OR CALL THE FRANCHISE TAX BOARD (FTB).
IF YOU ARE CALLING FROM WITHIN THE UNITED STATES
800-852-5711 (voice)
800-822-6268 (TTY)
IF YOU ARE CALLING FROM OUTSIDE THE UNITED STATES (Not Toll Free)
916-845-6500
The California Employer’s Guide (DE 44) provides the income tax withholding tables. This publication may be found on the
Employment Development Department (EDD) website at www.edd.ca.gov/Payroll_Taxes/Forms_and_Publications.htm. To assist
you in calculating your tax liability, please visit the Franchise Tax Board website at www.ftb.ca.gov/individuals/index.shtml.
NOTIFICATION: Your employer is required to send a
copy of your DE 4 to the FTB if it meets either of the
following two conditions:
• You claim more than 10 withholding allowances.
• You claim exemption from state or federal income tax
withholding and your employer expects your usual
weekly wages to exceed $200 per week.
IF THE IRS INSTRUCTS YOUR EMPLOYER TO
WITHHOLD FEDERAL INCOME TAX BASED ON
A CERTAIN WITHHOLDING STATUS, YOUR
EMPLOYER IS REQUIRED TO USE THE SAME
WITHHOLDING STATUS FOR STATE INCOME
TAX WITHHOLDING IF YOUR WITHHOLDING
ALLOWANCES FOR STATE PURPOSES MEET THE
REQUIREMENTS LISTED UNDER “NOTIFICATION.”
IF YOU FEEL THAT THE FEDERAL DETERMINATION
IS NOT CORRECT FOR STATE WITHHOLDING
PURPOSES, YOU MAY REQUEST A REVIEW.
DE 4 Rev. 43 (1-15) (INTERNET)
To do so, write to:
W-4 Unit
Franchise Tax Board MS F180
P.O. Box 2952
Sacramento, CA 95812-2952
Fax: 916-843-1094
Your letter should contain the basis of your request for
review. You will have the burden of showing that the
federal determination is incorrect for state withholding
purposes. The FTB will limit its review to that issue. The
FTB will notify both you and your employer of its findings.
Your employer is then required to withhold state income
tax as instructed by the FTB. In the event the FTB or the
IRS finds there is no reasonable basis for the number
of withholding exemptions that you claimed on your
Form W-4/DE 4, you may be subject to a penalty.
PENALTY: You may be fined $500 if you file, with no
reasonable basis, a DE 4 that results in less tax being
withheld than is properly allowable. In addition, criminal
penalties apply for willfully supplying false or fraudulent
information or failing to supply information requiring an
increase in withholding. This is provided for by Section
13101 of the California Unemployment Insurance Code.
Page 2 of 4
INSTRUCTIONS — 1 — ALLOWANCES*
When determining your withholding allowances, you must consider
your personal situation:
— Do you claim allowances for dependents or blindness?
— Will you itemize your deductions?
— Do you have more than one income coming into the household?
TWO-EARNER/TWO-JOBS: When earnings are derived from more
than one source, underwithholding may occur. If you have a working
spouse or more than one job, it is best to check the box “SINGLE
or MARRIED (with two or more incomes).” Figure the total number
of allowances you are entitled to claim on all jobs using only one
DE 4 form. Claim allowances with one employer. Do not claim the
same allowances with more than one employer. Your withholding
will usually be most accurate when all allowances are claimed
on the DE 4 or Form W-4 filed for the highest paying job and zero
allowances are claimed for the others.
WORKSHEET A
MARRIED BUT NOT LIVING WITH YOUR SPOUSE: You may
check the “Head of Household” marital status box if you meet all
of the following tests:
(1) Your spouse will not live with you at any time during the year;
(2) You will furnish over half of the cost of maintaining a home
for the entire year for yourself and your child or stepchild who
qualifies as your dependent; and
(3) You will file a separate return for the year.
HEAD OF HOUSEHOLD: To qualify, you must be unmarried or
legally separated from your spouse and pay more than 50% of the
costs of maintaining a home for the entire year for yourself and your
dependent(s) or other qualifying individuals. Cost of maintaining the
home includes such items as rent, property insurance, property taxes,
mortgage interest, repairs, utilities, and cost of food. It does not include
the individual’s personal expenses or any amount which represents value
of services performed by a member of the household of the taxpayer.
REGULAR WITHHOLDING ALLOWANCES
.......................................
Allowance for your spouse (if not separately claimed by your spouse) — enter 1 . . . . . . . . . . . . . . .
Allowance for blindness — yourself — enter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Allowance for blindness — your spouse (if not separately claimed by your spouse) — enter 1 . . . . . . . .
Allowance(s) for dependent(s) — do not include yourself or your spouse . . . . . . . . . . . . . . . . . . .
Total — add lines (A) through (E) above . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(A) Allowance for yourself — enter 1
(A)
(B)
(B)
(C)
(D)
(E)
(F)
(C)
(D)
(E)
(F)
INSTRUCTIONS — 2 — ADDITIONAL WITHHOLDING ALLOWANCES
If you expect to itemize deductions on your California income tax return, you can claim additional withholding allowances. Use Worksheet B to
determine whether your expected estimated deductions may entitle you to claim one or more additional withholding allowances. Use last year’s
FTB Form 540 as a model to calculate this year’s withholding amounts.
Do not include deferred compensation, qualified pension payments, or flexible benefits, etc., that are deducted from your gross pay but are not
taxed on this worksheet.
You may reduce the amount of tax withheld from your wages by claiming one additional withholding allowance for each $1,000, or fraction of
$1,000, by which you expect your estimated deductions for the year to exceed your allowable standard deduction.
WORKSHEET B
ESTIMATED DEDUCTIONS
1. Enter an estimate of your itemized deductions for California taxes for this tax year as listed in the
schedules in the FTB Form 540 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.....
1. __________________________
2. Enter $7,984 if married filing joint with two or more allowances, unmarried head of household, or
qualifying widow(er) with dependent(s) or $3,992 if single or married filing separately, dual income
married, or married with multiple employers . . . . . . . . . . . . . . . . . . . . . . . . . . . .
–
2. __________________________
3.
=
3. __________________________
+
4. __________________________
=
5. __________________________
–
6. __________________________
=
7. __________________________
4.
5.
6.
....
Subtract line 2 from line 1, enter difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter an estimate of your adjustments to income (alimony payments, IRA deposits) . . . . . . . . . . . .
Add line 4 to line 3, enter sum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter an estimate of your nonwage income (dividends, interest income, alimony receipts) . . . . . . . . .
7. If line 5 is greater than line 6 (if less, see below);
Subtract line 6 from line 5, enter difference . .
8.
..............................
Divide the amount on line 7 by $1,000, round any fraction to the nearest whole number . . . . . . . . .
Enter this number on line 1 of the DE 4. Complete Worksheet C, if needed.
9. If line 6 is greater than line 5;
Enter amount from line 6 (nonwage income)
10.
11.
................................
Enter amount from line 5 (deductions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Subtract line 10 from line 9, enter difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Complete Worksheet C
8. __________________________
9. __________________________
10. __________________________
11. __________________________
*Wages paid to registered domestic partners will be treated the same for state income tax purposes as wages paid to spouses for California Personal
Income Tax (PIT) withholding and PIT wages. This law does not impact federal income tax law. A registered domestic partner means an individual partner
in a domestic partner relationship within the meaning of Section 297 of the Family Code. For more information, please call our Taxpayer Assistance Center
at 888-745-3886.
DE 4 Rev. 43 (1-15) (INTERNET)
Page 3 of 4
WORKSHEET C
TAX WITHHOLDING AND ESTIMATED TAX
.................................
Enter estimate of nonwage income (line 6 of Worksheet B) . . . . . . . . . . . . . . . . . . . . . . . . . . .
Add line 1 and line 2. Enter sum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter itemized deductions or standard deduction (line 1 or 2 of Worksheet B, whichever is largest) . . . . . .
Enter adjustments to income (line 4 of Worksheet B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Add line 4 and line 5. Enter sum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Subtract line 6 from line 3. Enter difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure your tax liability for the amount on line 7 by using the 2015 tax rate schedules below . . . . . . . . .
Enter personal exemptions (line F of Worksheet A x $118.80) . . . . . . . . . . . . . . . . . . . . . . . . .
Subtract line 9 from line 8. Enter difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter any tax credits. (See FTB Form 540) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Subtract line 11 from line 10. Enter difference. This is your total tax liability . . . . . . . . . . . . . . . . . .
1. Enter estimate of total wages for tax year 2015
1.
2.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13. Calculate the tax withheld and estimated to be withheld during 2015. Contact your employer to
request the amount that will be withheld on your wages based on the marital status and number of
withholding allowances you will claim for 2015. Multiply the estimated amount to be withheld by
the number of pay periods left in the year. Add the total to the amount already withheld for 2015 .
......
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14. Subtract line 13 from line 12. Enter difference. If this is less than zero, you do not need to have additional
taxes withheld . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14.
15.
15.
..
Divide line 14 by the number of pay periods remaining in the year. Enter this figure on line 2 of the DE 4 . . .
NOTE: Your employer is not required to withhold the additional amount requested on line 2 of your DE 4. If your employer does not
agree to withhold the additional amount, you may increase your withholdings as much as possible by using the “single” status with “zero”
allowances. If the amount withheld still results in an underpayment of state income taxes, you may need to file quarterly estimates on
Form 540-ES with the FTB to avoid a penalty.
THESE TABLES ARE FOR CALCULATING WORKSHEET C AND FOR 2015 ONLY
SINGLE OR MARRIED WITH DUAL EMPLOYERS
IF THE TAXABLE INCOME IS
OVER
$0
$7,749
$18,371
$28,995
$40,250
$50,869
$259,844
$311,812
$519,687
$1,000,000
BUT NOT
OVER
$7,749 ...
$18,371 ...
$28,995 ...
$40,250 ...
$50,869 ...
$259,844 ...
$311,812 ...
$519,687 ...
$1,000,000 ...
and over
MARRIED FILING JOINT OR QUALIFYING WIDOW(ER) TAXPAYERS
COMPUTED TAX IS
OF AMOUNT
OVER . . .
IF THE TAXABLE INCOME IS
PLUS*
OVER
1.100%
$0
$0.00
2.200%
$7,749
$85.24
4.400%
$18,371
$318.92
6.600%
$28,995
$786.38
8.800%
$40,250
$1,529.21
10.230%
$50,869
$2,463.68
11.330% $259,844 $23,841.82
12.430% $311,812 $29,729.79
13.530% $519,687 $55,568.65
14.630% $1,000,000 $120,555.00
$0
$15,498
$36,742
$57,990
$80,500
$101,738
$519,688
$623,624
$1,000,000
$1,039,374
BUT NOT
OVER
$15,498 ...
$36,742 ...
$57,990 ...
$80,500 ...
$101,738 ...
$519,688 ...
$623,624 ...
$1,000,000 ...
$1,039,374 ...
and over
COMPUTED TAX IS
OF AMOUNT
OVER . . .
PLUS*
1.100%
$0
$0.00
2.200%
$15,498
$170.48
4.400%
$36,742
$637.85
6.600%
$57,990
$1,572.76
8.800%
$80,500
$3,058.42
10.230% $101,738
$4,927.36
11.330% $519,688 $47,683.65
12.430% $623,624 $59,459.60
13.530% $1,000,000 $106,243.14
14.630% $1,039,374 $111,570.44
UNMARRIED HEAD OF HOUSEHOLD TAXPAYERS
IF THE TAXABLE INCOME IS
OVER
$0
$15,508
$36,743
$47,366
$58,621
$69,242
$353,387
$424,065
$706,774
$1,000,000
BUT NOT
OVER
$15,508 ...
$36,743 ...
$47,366 ...
$58,621 ...
$69,242 ...
$353,387 ...
$424,065 ...
$706,774 ...
$1,000,000 ...
and over
COMPUTED TAX IS
OF AMOUNT
OVER . . .
PLUS*
1.100%
$0
$0.00
2.200%
$15,508
$170.59
4.400%
$36,743
$637.76
6.600%
$47,366
$1,105.17
8.800%
$58,621
$1,848.00
10.230%
$69,242
$2,782.65
11.330% $353,387 $31,850.68
12.430% $424,065 $39,858.50
13.530% $706,774 $74,999.23
14.630% $1,000,000 $114,672.71
IF YOU NEED MORE DETAILED INFORMATION, SEE THE INSTRUCTIONS THAT
CAME WITH YOUR LAST CALIFORNIA INCOME TAX RETURN OR CALL THE FTB:
IF YOU ARE CALLING FROM WITHIN THE UNITED STATES
800-852-5711 (voice)
800-822-6268 (TTY)
IF YOU ARE CALLING FROM OUTSIDE THE UNITED STATES
(Not Toll Free)
916-845-6500
*marginal tax
The DE 4 information is collected for purposes of administering the PIT law and under the authority of Title 22, California Code of
Regulations, and the Revenue and Taxation Code, including Section 18624. The Information Practices Act of 1977 requires that individuals
be notified of how information they provide may be used. Further information is contained in the instructions that came with your last
California income tax return.
DE 4 Rev. 43 (1-15) (INTERNET)
Page 4 of 4
Department of Revenue Services
State of Connecticut
(Rev. 01/15)
Effective January 1, 2015
Form CT-W4
Employee’s Withholding Certificate
Complete this form in blue or black ink only.
Employee Instructions
• Read instructions on Page 2 before completing this form.
• Select the filing status you expect to report on your Connecticut
income tax return. See instructions.
• Choose the statement that best describes your gross income.
• Enter the Withholding Code on Line 1 below.
Withholding
Code
Married Filing Jointly
Our expected combined annual gross income is less than or
equal to $24,000 or I am claiming exemption under the Military
Spouses Residency Relief Act (MSRRA)* and no withholding
is necessary.
E
My spouse is employed and our expected combined annual
gross income is greater than $24,000 and less than or equal
to $100,500. See Certain Married Individuals, Page 2.
A
My spouse is not employed and our expected combined
annual gross income is greater than $24,000.
C
My spouse is employed and our expected combined
annual gross income is greater than $100,500.
D
I have significant nonwage income and wish to avoid having
too little tax withheld.
D
I am a nonresident of Connecticut with substantial other income.
D
Withholding
Code
Qualifying Widow(er) With Dependent Child
Married Filing Separately
Withholding
Code
My expected annual gross income is less than or equal to
$12,000 or I am claiming exemption under the MSRRA* and
no withholding is necessary.
E
My expected annual gross income is greater than $12,000.
A
I have significant nonwage income and wish to avoid having
too little tax withheld.
D
I am a nonresident of Connecticut with substantial other income.
D
Single
Withholding
Code
My expected annual gross income is less than or equal to
$15,000 and no withholding is necessary.
E
My expected annual gross income is greater than $15,000.
F
I have significant nonwage income and wish to avoid having
too little tax withheld.
D
I am a nonresident of Connecticut with substantial other income.
D
Head of Household
Withholding
Code
My expected annual gross income is less than or equal to
$24,000 or I am claiming exemption under the MSRRA* and
no withholding is necessary.
E
My expected annual gross income is less than or equal to
$19,000 and no withholding is necessary.
E
My expected annual gross income is greater than $24,000.
C
My expected annual gross income is greater than $19,000.
B
I have significant nonwage income and wish to avoid having too
little tax withheld.
D
I have significant nonwage income and wish to avoid having
too little tax withheld.
D
I am a nonresident of Connecticut with substantial other income.
D
I am a nonresident of Connecticut with substantial other income.
D
* If you are claiming the Military Spouses Residency Relief Act (MSRRA) exemption, see instructions on Page 2.
Employees: See Employee General Instructions on Page 2. Sign and return Form CT-W4 to your employer. Keep a copy for your records.
if you are claiming
 Check
the MSRRA exemption
1. Withholding Code: Enter Withholding Code letter chosen from above. ....................... 1.
2. Additional withholding amount per pay period: If any, see Page 3 instructions. .......... 2. $
and enter state of legal
residence/domicile:
3. Reduced withholding amount per pay period: If any, see Page 3 instructions. ............ 3. $
_____________________
First name
Ml
Last name
Social Security Number
Home address (number and street, apartment number, suite number, PO Box)
City/town
State
ZIP code
Declaration: I declare under penalty of law that I have examined this certificate and, to the best of my knowledge and belief, it is true, complete, and
correct. I understand the penalty for reporting false information is a fine of not more than $5,000, imprisonment for not more than five years, or both.
Employee’s signature
Date
Employers: See Employer Instructions on Page 2.
Is this a new or rehired employee?

No

Yes  Enter date hired:
Employer’s business name
mm/dd/yyyy
Federal Employer Identification Number
Employer’s business address
City/town
Contact person
State
ZIP code
Telephone number
(
)
Employee General Instructions
Form CT-W4, Employee’s Withholding Certificate, provides your
employer with the necessary information to withhold the correct
amount of Connecticut income tax from your wages to ensure that
you will not be underwithheld or overwithheld.
You are required to pay Connecticut income tax as income is earned
or received during the year. You should complete a new Form CT-W4
at least once a year or if your tax situation changes.
If your circumstances change, such as you receive a bonus or your
filing status changes, you must furnish your employer with a new
Form CT-W4 within ten days of the change.
To minimize this problem, use the Supplemental Table on Page 3 and
Page 4 to adjust your withholding. You are not required to use this
table. Do not use the supplemental table to adjust your withholding
if you use the worksheet in IP 2015(7).
Armed Forces Personnel and Veterans
If you are a Connecticut resident, your armed forces pay is subject
to Connecticut income tax withholding unless you qualify as a
nonresident for Connecticut income tax purposes. If you qualify as
a nonresident, you may request that no Connecticut income tax be
withheld from your armed forces pay by entering Withholding Code
“E” on Line 1.
Gross Income
For Form CT-W4 purposes, gross income means all income from
all sources, whether received in the form of money, goods, property,
or services, not exempt from federal income tax, and includes any
additions to income from Schedule 1 of Form CT-1040, Connecticut
Resident Income Tax Return or Form CT-1040NR/PY, Connecticut
Nonresident and Part-Year Resident Return.
Military Spouses Residency Relief Act (MSRRA)
If you are claiming an exemption from Connecticut income tax under
the MSRRA, you must provide your employer with a copy of your
military spouse’s Leave and Earnings Statement (LES) and a copy
of your military dependent ID card.
See Informational Publication 2012(15), Connecticut Income Tax
Information for Armed Forces Personnel and Veterans.
Filing Status
Generally, the filing status you expect to report on your Connecticut
income tax return is the same as the filing status you expect to report
on your federal income tax return. However, special rules apply to
married individuals who file a joint federal return but have a different
residency status. Nonresidents and part-year residents should see
the instructions to Form CT-1040NR/PY.
Check Your Withholding
You may be underwithheld if any of the following apply:
• You have more than one job;
• You qualify under Certain Married Individuals and do not use the
Supplemental Table on Page 3 and Page 4; or
• You have substantial nonwage income.
If you are underwithheld, you should consider adjusting your
withholding or making estimated payments using Form CT-1040ES,
Estimated Connecticut Income Tax Payment Coupon for Individuals.
You may also select Withholding Code “D” to elect the highest level
of withholding.
If you owe $1,000 or more in Connecticut income tax over and above
what has been withheld from your income for the prior taxable year,
you may be subject to interest on the underpayment at the rate of 1%
per month or fraction of a month.
You may be overwithheld if your combined annual income is more than
$200,000 but less than $700,000 and your Connecticut filing status
is filing jointly. To help determine if your withholding is correct, see
Informational Publication 2015(7), Is My Connecticut Withholding
Correct?
Employer Instructions
Nonresident Employees Working Partly Within and Partly
Outside of Connecticut
If you work partly within and partly outside of Connecticut for the same
employer, you should also complete Form CT-W4NA, Employee’s
Withholding or Exemption Certificate - Nonresident Apportionment,
and provide it to your employer. The information on Form CT-W4NA
and Form CT-W4 will help your employer determine how much to
withhold from your wages for services performed within Connecticut.
To obtain Form CT-W4NA, visit the Department of Revenue Services
(DRS) website at www.ct.gov/DRS or request the form from your
employer. Any nonresident who expects to have no Connecticut
income tax liability should choose Withholding Code “E.”
Certain Married Individuals
If you are a married individual filing jointly and you and your spouse
both select Withholding Code “A,” you may have too much or too
little Connecticut income tax withheld from your pay. This is because
the phase-out of the personal exemption and credit is based on your
combined incomes. The withholding tables cannot reflect your exact
withholding requirement without considering the income of your
spouse.
Form CT-W4 (Rev. 01/15)
For any employee who does not complete Form CT-W4, you are required
to withhold at the highest marginal rate of 6.7% without allowance for
exemption. You are required to keep Form CT-W4 in your files for
each employee. See Informational Publication 2015(1), Connecticut
Employer’s Tax Guide, Circular CT, for complete instructions.
Report Certain Employees Claiming Exemption From Withholding
to DRS
Employers are required to file copies of Form CT-W4 with DRS for
certain employees claiming “E” (no withholding is necessary). See
IP 2015(1). Mail copies of Forms CT-W4 meeting the conditions listed
in IP 2015(1) under Reporting Certain Employees to:
Department of Reveunue Services
PO Box 2931
Hartford CT 06104-2931
Report New and Rehired Employees to the Department of Labor
New employees are workers not previously employed by your
business, or workers rehired after having been separated from your
business for more than sixty consecutive days.
Employers with offices in Connecticut or transacting business in
Connecticut are required to report new hires to the Department of
Labor (DOL) within 20 days of the date of hire.
New hires can be reported by:
• Using the Connecticut New Hire Reporting website at
www.ctnewhires.com;
• Faxing copies of completed Forms CT-W4 to 800-816-1108; or
• Mailing copies of completed Forms CT-W4 to:
Department of Labor
Office of Research, Form CT-W4
200 Folly Brook Boulevard
Wethersfield CT 06109
For more information on DOL requirements or for alternative reporting
options, visit the DOL website at www.ctdol.state.ct.us or call DOL
at 860-263-6310.
For More Information
Call DRS during business hours, Monday through Friday:
• 800-382-9463 (Connecticut calls outside the Greater Hartford
calling area only); or
• 860-297-5962 (from anywhere).
TTY, TDD, and Text Telephone users only may transmit inquiries
anytime by calling 860-297-4911.
Forms and Publications
Visit the DRS website at www.ct.gov/DRS to download and print
Connecticut tax forms and publications.
Page 2 of 4
Page 3 of 4
(Rev. 01/15)
3,000
6,000
9,000
12,000
15,000
18,000
21,000
24,000
27,000
30,000
33,000
36,000
39,000
42,000
45,000
48,000
51,000
54,000
57,000
60,000
63,000
66,000
69,000
72,000
75,000
78,000
81,000
84,000
87,000
90,000
93,000
96,000
99,000
2,000
0
0
0
0
(23)
(99)
(203)
(325)
(586)
(792)
(956)
(1,167)
(1,193)
(1,200)
(1,208)
(1,130)
(1,110)
(1,120)
(1,035)
(950)
(885)
(800)
(715)
(720)
(770)
(800)
(830)
(860)
(890)
(920)
(950)
(800)
(500)
4,000
6,000
0
0
0
0
0
0
0
0
(23)
(23)
(99)
(99)
(195)
(180)
(310)
(295)
(550)
(475)
(705)
(666)
(917)
(878)
(1,128)
(981)
(1,091) (1,023)
(1,115) (1,030)
(1,080)
(888)
(912)
(720)
(930)
(750)
(940)
(760)
(855)
(675)
(770)
(590)
(705)
(525)
(620)
(440)
(580)
(490)
(630)
(540)
(680)
(590)
(710)
(620)
(740)
(650)
(770)
(680)
(800)
(710)
(830)
(740)
(771)
(497)
(552)
(280)
8,000
0
0
0
0
(23)
(84)
(165)
(232)
(409)
(627)
(788)
(930)
(938)
(860)
(675)
(540)
(570)
(580)
(495)
(410)
(345)
(350)
(400)
(450)
(500)
(530)
(560)
(590)
(620)
(470)
(170)
12,000
0
0
0
0
0
(54)
(54)
(106)
(331)
(441)
(618)
(760)
(618)
(450)
(315)
(180)
(210)
(220)
(135)
(50)
(120)
(170)
(220)
(270)
(320)
(350)
(380)
(410)
(167)
50
14,000 16,000
(15)
(42)
(15)
(42)
(15)
(35)
0
(12)
0
9
(6)
54
(3)
9
(82)
(70)
(256)
(181)
(405)
(347)
(548)
(447)
(605)
(414)
(420)
(267)
(285)
(132)
(150)
3
(15)
138
(45)
108
(55)
98
30
138
25
88
(45)
18
(95)
(32)
(145)
(82)
(195)
(132)
(245)
(182)
(275)
(212)
(305)
(153)
(155)
96
145
18,000
(99)
(99)
(77)
(54)
27
36
(9)
20
(170)
(319)
(312)
(279)
(144)
(9)
126
261
231
221
171
121
51
1
(49)
(99)
(149)
(179)
64
281
This table joins the table on Page 4.
10,000
0
0
0
0
(15)
(69)
(129)
(145)
(370)
(588)
(686)
(845)
(810)
(642)
(495)
(360)
(390)
(400)
(315)
(230)
(210)
(260)
(310)
(360)
(410)
(440)
(470)
(500)
(441)
(192)
Pay periods
in a year:
22,000
(248)
(225)
(182)
(60)
(24)
(42)
27
0
(113)
(87)
(75)
(75)
60
195
330
465
390
245
195
145
75
25
(25)
(75)
(36)
213
24,000
(318)
(295)
(192)
(106)
(70)
20
10
0
(6)
20
20
20
155
290
425
560
395
250
200
150
80
30
(20)
(70)
153
370
26,000
(485)
(414)
(308)
(249)
(162)
(111)
(87)
(12)
25
18
18
18
153
288
423
468
303
158
108
58
(12)
(62)
(112)
18
298
Weekly .......................52
Biweekly .......................26
Semi-monthly ................24
Monthly .......................12
If you are paid:
20,000
(156)
(141)
(119)
(48)
36
18
24
14
(142)
(206)
(156)
(156)
(21)
114
249
384
354
254
204
154
84
34
(16)
(66)
(116)
34
334
Reading across the top of the table, select the approximate annual wage income of one spouse. Reading down the left
column, select the approximate annual wage income of the other spouse. See Page 4 for the continuation of this table.
At the intersection of the two numbers is an adjustment amount. This is a yearly adjustment amount.
To calculate the adjustment for each pay period, complete the following worksheet.
A.
Adjustment amount
3A.________________
B.
Pay periods in a year: See pay period table.
3B.________________
C. Pay period adjustment: Divide Line 3A by Line 3B.
3C.________________
If the adjustment is positive, enter the adjustment amount from Line 3C on Form CT-W4, Line 2, of one spouse. If the
adjustment is negative, enter the adjustment amount in brackets from Line 3C on Form CT-W4, Line 3, of one spouse.
Annual Salary
4.
2.
3.
1.
For married couples who both select Withholding Code “A” on Form CT-W4 (combined income is $100,500 or less).
Instructions
Pay Period Table
Supplemental Table
Married Couples Filing Jointly - Effective January 1, 2015
Form CT-W4 Effective January 1, 2015
(Rev. 01/15)
3,000
6,000
9,000
12,000
15,000
18,000
21,000
24,000
27,000
30,000
33,000
36,000
39,000
42,000
45,000
48,000
51,000
54,000
57,000
60,000
63,000
66,000
69,000
72,000
(647)
(525)
(467)
(408)
(258)
(224)
(158)
8
7
0
0
0
135
270
360
360
195
50
0
(50)
(120)
(170)
(131)
98
Annual Salary 28,000
30,000
(752)
(666)
(608)
(441)
(370)
(319)
(146)
20
7
0
0
0
135
270
270
270
105
(40)
(90)
(140)
(210)
(260)
(37)
160
32,000 34,000 36,000 38,000 40,000 42,000 44,000
(866) (1,007) (1,148) (1,148) (1,136) (1,158) (1,163)
(807)
(948)
(981) (1,020) (1,025) (1,030)
(950)
(698)
(776)
(888)
(893)
(855)
(753)
(630)
(570)
(665)
(760)
(680)
(552)
(450)
(360)
(465)
(518)
(506)
(383)
(293)
(203)
(113)
(329)
(291)
(279)
(189)
(99)
(9)
81
(113)
(113)
(113)
(23)
68
158
248
20
20
20
110
200
290
380
7
7
7
97
187
277
367
0
0
0
90
180
270
270
0
0
0
90
135
135
135
0
0
0
0
0
0
0
135
90
0
0
0
0
0
180
90
0
0
0
0
0
180
90
0
0
0
0
0
180
90
0
0
0
0
0
15
(75)
(165)
(165)
(165)
(165)
(165)
(130)
(220)
(310)
(310)
(310)
(310)
(130)
(180)
(270)
(360)
(360)
(271)
(87)
150
(230)
(320)
(410)
(230)
(42)
110
(300)
(301)
(207)
30
(170)
(72)
(10)
110
This table joins the table on Page 3.
46,000
(1,125)
(822)
(540)
(270)
(23)
171
338
470
412
270
135
0
0
0
0
0
(76)
58
48,000
(1,023)
(720)
(450)
(180)
68
261
428
560
412
270
135
0
0
0
0
0
108
210
50,000
(992)
(722)
(452)
(182)
66
259
426
468
320
178
43
(92)
(92)
(92)
(92)
88
253
For married couples who both select Withholding Code “A” on Form CT-W4 (combined income is $100,500 or less).
Supplemental Table
Married Couples Filing Jointly - Effective January 1, 2015
52,000
(1,031)
(761)
(491)
(221)
26
220
341
339
191
49
(86)
(221)
(221)
(221)
(132)
147
Form CT-W4 Effective January 1, 2015
Page 4 of 4
Government of the
District of Columbia
D-4 D
C Withholding
Allowance Certificate
Enter Year
Social security number
FIrst name M.I.
Home address (number and street) Last name
City
State
Single
Zip code +4
1
Tax filing status Fill in only one: Married/domestic partners filing jointly
2
Total number of withholding allowances from worksheet below.
Enter total from Sec. A, Line i
3
Additional amount, if any, you want withheld from each paycheck 4
Before claiming exemption from withholding, read below. If qualified, write “EXEMPT” in this box.
5
My domicile is a state other than the District of Columbia
I am exempt because: last year I did not owe any DC income tax and had a right to a full refund of all DC income tax withheld from me; and this year I do
not expect to owe any DC income tax and expect a full refund of all DC income tax withheld from me; and I qualify for exempt status on federal Form W-4.
If claiming exemption from withholding, are you a full-time student?
Head of household
Signature
Married filing separately
Married/domestic partners filing separately on same return
Enter total from Sec. B, Line o
Yes
Total number of withholding allowances
$
4
No If yes, give name of state of domicile __________________
Yes
No
Under penalties of law, I declare that the information provided on this certificate is, to the best of my knowledge, correct.
Employee’s signature
Date
Employer
Keep this certificate with your records. If 10 or more exemptions are claimed or if you suspect this certificate contains false information
please send a copy to: Office of Tax and Revenue, 1101 4th St., SW, Washington, DC 20024 Attn: Compliance Administration
Detach and give the top portion to your employer. Keep the bottom portion for your records.
Government of the
District of Columbia
D-4 DC Withholding Allowance Worksheet
Section A Number of withholding allowances
a Enter 1 for yourself a
b Enter 1 if you are filing as a head of household b
c Enter 1 if you are 65 or over c
d Enter 1 if you are blind
d
e Enter number of dependents
e
f Enter 1 for your spouse/registered domestic partner if filing jointly f
g Enter 1 if married/registered domestic partners filing jointly and your spouse/registered domestic partner is 65 or over g
h Enter 1 if married/registered domestic partners filing jointly and your spouse/registered domestic partner is blind h
i
i
Number of allowances . Add Lines a through h and enter on Line 2 above. If you want to claim additional withholding
allowances, complete section B below.
Section B Additional withholding allowances
j
Enter estimate of your itemized deductions j
k Enter $2,000 if married/registered domestic partners filing separately; all others enter $4,000 k
l
l
Subtract Line k from Line j
m Multiply $1,675 by the number of allowances on Line i
m
n Divide Line l by Line m. Round to the nearest whole number.
n
o Add Lines n and i and enter on Line 2 above. o
D-4 P1
DC Withholding Allowance Certificate
Revised 12/2011
Detach and give the top portion to your employer. Keep the bottom portion for your records.
Who must file a Form D-4?
Every new employee who resides in DC and is required to have DC
income taxes withheld, must fill out Form D-4 and file it with his/her
employer.
If you are not liable for DC income taxes because you are a nonresident
or military spouse, you must file Form D-4A, Certificate of Nonresidence in the District of Columbia, with your employer.
When should you file?
File Form D-4 whenever you start new employment. Once filed
with your employer, it will remain in effect until you file a new
certificate. You may file a new withholding allowance certificate
any time the number of withholding allowances you are entitled to
increases. You must file a new certificate within 10 days if the number
of withholding allowances you claimed decreases.
How many withholding allowances should you claim?
Use the worksheet on the front of this form to figure the number
of withholding allowances you should claim. If you want less
money withheld from your paycheck, you may claim additional
allowances by completing Section B of the worksheet, Lines j through
o. However, if you claim too many allowances, you may owe additional
taxes at the end of the year.
Should I have an additional amount deducted from my paycheck?
In some instances, even if you claim zero withholding allowances,
you may not have enough tax withheld. You may, upon agreement
with your employer, have more tax withheld by entering on Line 3,
a dollar amount of your choosing.
What to file
After completing Form D-4, detach the top portion and file it with
your employer. Keep the bottom portion for your records.
GUIDELINES FOR STATE WITHHOLDING FORMS
State
AL
AZ
AR
CA
CT
DC
GA
HI
IL
IN
IA
KY
LA
ME
MD
MA
MI
Form Name
A-4
A-4
AR4EC
DE 4
CT-W4
D-4
G-4
HW-4
IL-W-4
WH-4
IA W4
K-4
R-1300 (L-4)
W-4ME
MW 507
M-4
MI-W4
Accepts Federal Form
No
No
Yes
Yes
No
No
Yes
No
No
No
No
No
No
No
No
Yes
No
MN
MS
MO
NJ
NY
NC
W-4MN
89-350
MO W4
NJ-W4
IT-2104
NC-4
Yes
No
No
Yes
Yes
No
OH
PR
VT
VA
WV
WI
IT-4
499 R-4.1
W-4VT
VA-4
WV/IT-104
WT-4
No
No
Yes
No
Yes
Yes
PA
Residency Certification Form
No
IN
Certificate of Residency
No
Notes - All states that do not accept the Federal W-4 form must have a state specific
form for all new hires
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required each time you change the number of allowances
Required when claiming fewer exemptions than Federal W-4, Claim more than 10 MN
withholding allowances, want additional MN withholding deducted per pay period
Required each time you change the number of allowances
Required each time you change the number of allowances
Required for all NYC and Yonkers residents
Required each time you change the number of allowances
Required each time you change the number of allowances and each time you move and
change school districts
Required each time you change the number of allowances
Required each time you change the number of allowances
Required for every address change
Required for employees that live in states with Reciprocity with IN that work in IN (KY,
MI, OH, PA, WI)
Clear Form
FORM HW-4
(REV. 2014)
STATE OF HAWAII — DEPARTMENT OF TAXATION
EMPLOYEE’S WITHHOLDING ALLOWANCE AND STATUS CERTIFICATE
INSTRUCTIONS
(NOTE: References to “married”, “unmarried”, and “spouse” also means “in a civil union”, “not in a civil union”, and “civil union partner”, respectively.)
MARITAL STATUS—If you are legally separated from your spouse
under a decree of divorce or separate maintenance, check the Single
box.
If you file as head of household on your tax return, you are treated as
Single for withholding tax purposes. However, an additional withholding
allowance may be claimed for this filing status.
NUMBER OF WITHHOLDING ALLOWANCES—Do not claim more than
the correct number of withholding allowances. However, if by claiming
the correct number of withholding allowances you still expect to owe
more income tax for the year than will be withheld, you may increase the
amount withheld either by claiming fewer withholding allowances or by
entering into an agreement with your employer to withhold an additional
dollar amount.
Note: Hawaii law does NOT allow “exempt” status for withholding purposes.
NONWAGE INCOME—If you have a large amount of nonwage income,
from sources such as interest or dividends, you should consider making
estimated tax payments using Form N-1 or you may find that you owe
additional tax at the end of the year.
TWO-EARNER/TWO JOBS—If you have a working spouse or more
than 1 job, figure the total number of allowances you are entitled to claim
on all jobs using worksheets from only 1 Form HW-4. This total should
be divided among all jobs. Your withholding will usually be most accurate
when all allowances are claimed on the HW-4 filed for the highest paying
job and zero allowances are claimed for the others.
FILING THE CERTIFICATE—You must file this form with your employer
or your employer must withhold tax from your wages as if you were
single and claimed no withholding allowances.
FILING A NEW CERTIFICATE—You SHOULD file a new certificate if
you get married or are entitled to claim more withholding allowances.
You MUST file a new certificate within 10 days if ANY of the following
occurs:
(a) If you are divorced or legally separated.
(b) If your spouse, for whom you have been claiming a withholding
allowance, commences claiming his or her own withholding
allowance on a separate certificate.
(c) If a dependent for whom you claimed a withholding allowance no
longer qualifies as a dependent.
You MUST file a new certificate on or before December 1 in case of the
death of your spouse or the death of a dependent, unless such event
occurs in December.
WITHHOLDING ALLOWANCE FOR AGE—You may claim an additional
withholding allowance for age if you are at least 65 years old and no
one can claim you as a dependent. If you are married and filing a joint
return, you may also claim an additional withholding allowance if your
spouse is at least 65 years old, no one else can claim your spouse as
a dependent, and your spouse is not already claiming such withholding
allowance for himself / herself on a Form HW-4.
HEAD OF HOUSEHOLD—Generally, you may claim head of household
filing status on your tax return only if you are unmarried and pay more
than 50% of the costs of keeping up a home for yourself and your
qualifying child or any other person who is your dependent.
PENALTIES—Penalties are imposed for willfully supplying false or
fraudulent information or for willfully failing to supply information.
CERTIFIED DISABLED PERSON—See the section, “What Is Not
Subject to Withholding” in Booklet A, Employer’s Tax Guide.
NONRESIDENT MILITARY SPOUSE—Under federal law, the State is
prohibited from subjecting the income received by a service member’s
nonresident spouse for services performed (i.e., wages) in Hawaii to
Hawaii’s income tax beginning tax year 2009.
FOR FURTHER INFORMATION—Contact your employer or the
Department of Taxation at 808-587-4242 (toll-free at 1-800-222-3229).
---------------------- Cut here and give the certificate to your employer. Keep the top portion and a copy of page 2 for your records.----------------------FORM HW-4
(REV. 2014)
STATE OF HAWAII — DEPARTMENT OF TAXATION
EMPLOYEE’S WITHHOLDING ALLOWANCE AND STATUS CERTIFICATE
Section A (to be completed by the employee)
1 Type or print your full name
2 Your Social Security Number
Home address (number and street or rural route)
3 Marital Status
City or town, State, and Postal/ZIP code
Single Married
Married, but withhold at higher Single rate
Certified Disabled Person (not subject to withholding)

Nonresident Military Spouse (not subject to withholding)
4 Total number of allowances you are claiming (from line I of the worksheet on page 2). (Note: Hawaii law
does NOT allow “EXEMPT” status for withholding purposes.)........................................................................................... 5 Additional amount, if any, you want deducted each pay period................................................................................................. 4
5 $
I declare, under the penalties set forth in section 231-36, HRS, that I have correctly indicated my marital status and that the number of withholding
allowances claimed on this certificate does not exceed the number to which I am entitled.
(Date)
, (Signed)
Section B (to be completed by the employer)
1 Employer’s name
2 Hawaii tax identification number
W __ __ __ __ __ __ __ __ - __ __
Employer’s address
City or town, State, and Postal/ZIP code
EMPLOYER: Keep this certificate with your records. If you believe that an employee has claimed excess allowances for the employee’s situation (generally
more than 10) or misstated the employee’s marital status, you must send a copy of the Form HW-4 for that employee to the Hawaii Department of Taxation,
P. O. Box 3827, Honolulu, Hawaii 96812-3827.
FORM HW-4
FORM HW-4 (REV. 2014)
Page 2
HW-4 Worksheet to Figure Your Withholding Allowances
A. Enter “1” for yourself if no one else can claim you as a dependent...................................................................................
B. Enter “1” if:
1.You are single and have only 1 job OR
2.You are married, have only 1 job, and your spouse does not work.......................................................
C. Enter “1” for your spouse if:
1. No one else can claim your spouse as a dependent AND
2. Your spouse is not claiming a withholding allowance for himself / herself
on a Form HW-4.......................................................................................................
D. You may be able to claim additional withholding allowances for age. See Instructions on page 1.
Enter “1” if you or your spouse qualifies. Enter “2” if both you and your spouse qualify.....................................................
E. Enter the number of dependents that you will claim on your tax return. (State qualifications
are the same as the federal)...............................................................................................................................................
F. Enter “1” if you will file as head of household on your tax return. See Instructions on page 1.......................................
G. Enter “1” if you estimate that you will have at least $250 of total tax credits....................................................................
H. If you plan to itemize or claim adjustments to income, complete the worksheet below and enter the number of
withholding allowances here from line 8.............................................................................................................................
I. Total. Add lines A through H. Enter the total here and on line 4 of Form HW-4 on page 1. (Note: This amount
may be different from the number of exemptions you claim on your return)......................................................................
A. B. C. D. E. F. G. H. I.
Deductions and Adjustments Worksheet
NOTE: Use this worksheet only if you plan to itemize deductions or claim adjustments to income.
1. Enter an estimate of your current year’s itemized deductions. These include: qualifying home mortgage interest,
charitable contributions, State and local taxes, medical expenses in excess of 10% of your adjusted gross income
for taxable years beginning after December 31, 2012 (for 2013-2016, if either the taxpayer or the taxpayer’s spouse
is age 65 or older at the end of the tax year, the threshold will remain at 7.5% of adjusted gross income), and
miscellaneous deductions. (You may have to reduce your itemized deductions if your income is over $166,800
($83,400 if married filing separately)).................................................................................................................................
$4,400* if married filing jointly or surviving spouse
2. Enter
$3,212* if head of household
.............................................................................
$2,200* if single
$2,200* if married filing separately
3. Line 1 minus line 2. Enter the result, but not less than zero..............................................................................................
4. Enter an estimate of your current year’s adjustments to income........................................................................................
5. Add lines 3 and 4 and enter the total..................................................................................................................................
6. Enter an estimate of your current year’s nonwage income (such as dividends or interest income)...................................
7. Line 5 minus line 6. Enter the result, but not less than zero..............................................................................................
8. Divide the amount on line 7 by $1,144**. Drop any fraction. Enter the result here and on the HW-4 worksheet,
line H above........................................................................................................................................................................
{
*
}
1$
2$
3$
4$
5$
6$
7$
8 Nonresidents and part-year residents: On line 2, enter the amount appropriate to your filing status multiplied by the ratio of your Hawaii adjusted
gross income to total adjusted gross income from all sources.
** Nonresidents and part-year residents: Divide the amount on line 7 by $1,144 multiplied by the ratio of your Hawaii adjusted gross income to total
adjusted gross income from all sources.
Illinois Department of Revenue
Form IL-W-4 Note: These instructions are written for employees to address withholding from wages.
However, this form can also be completed and
submitted to a payor if an agreement was made
to voluntarily withhold Illinois Income tax from
other (non-wage) Illinois income.
Who must complete Form IL-W-4?
If you are an employee, you must complete
this form so your employer can withhold the
correct amount of Illinois Income Tax from
your pay. The amount withheld from your pay
depends, in part, on the number of allowances you claim on this form.
Even if you claimed exemption from withholding on your federal Form W-4, U.S.
Employee’s Withholding Allowance Certificate, because you do not expect to
owe any federal income tax, you may be
required to have Illinois Income Tax withheld from your pay (see Publication 130,
Who is Required to Withhold Illinois Income Tax). If you are claiming exempt
status from Illinois withholding, you must
check the exempt status box on Form
IL-W-4 and sign and date the certificate. Do
not complete Lines 1 through 3.
If you are a resident of Iowa, Kentucky,
Michigan, or Wisconsin, or a military spouse,
see Form W-5-NR, Employees Statement of
Nonresidence in Illinois, to determine if you
are exempt.
If you do not file a completed Form
IL-W-4 with your employer, if you fail to sign
the form or to include all necessary information, or if you alter the form, your employer
must withhold Illinois Income Tax on the
entire amount of your compensation, without
allowing any exemptions.
When must I submit this form?
You should complete this form and give it
to your employer on or before the date you
start work. You must submit Form IL-W-4
when Illinois Income Tax is required to be
withheld from compensation that you receive
as an employee. You may file a new Form
IL‑W-4 any time your withholding allowances
increase. If the number of your claimed allowances decreases, you must file a new
Form IL-W-4 within 10 days. However, the
death of a spouse or a dependent does not
affect your withholding allowances until the
next tax year.
When does my Form IL-W-4
take effect?
If you do not already have a Form IL-W-4
on file with your employer, this form will be
IL-W-4 (R-12/14)
Employee’s and other Payee’s Illinois Withholding
Allowance Certificate and Instructions
effective for the first payment of compensation made to you after this form is filed. If
you already have a Form IL-W-4 on file with
this employer, your employer may allow any
change you file on this form to become effective immediately, but is not required by law
to change your withholding until the first payment of compensation is made to you after
the first day of the next calendar quarter (that
is, January 1, April 1, July 1, or October 1)
that falls at least 30 days after the date you
file the change with your employer.
Example: If you have a baby and file a
new Form IL-W-4 with your employer to
claim an additional allowance for the baby,
your employer may immediately change
the withholding for all future payments of
compensation. However, if you file the new
form on September 1, your employer does
not have to change your withholding until the
first payment of compensation is made to
you after October 1. If you file the new form
on September 2, your employer does not
have to change your withholding until the first
payment of compensation made to you after
December 31.
How long is Form IL-W-4 valid?
Your Form IL-W-4 remains valid until a new
form you have submitted takes effect or until
your employer is required by the Department
to disregard it. Your employer is required to
disregard your Form IL-W-4 if
• you claim total exemption from Illinois
Income Tax withholding, but you have
not filed a federal Form W-4 claiming
total exemption, or
• the Internal Revenue Service (IRS) has
instructed your employer to disregard
your federal Form W-4.
What is an “exemption”?
An “exemption” is a dollar amount on which
you do not have to pay Illinois Income Tax
that you may claim on your Illinois Income
tax return.
What is an “allowance”?
The dollar amount that is exempt from
Illinois Income Tax is based on the number
of allowances you claim on this form. As an
employee, you receive one allowance unless
you are claimed as a dependent on another
person’s tax return (e.g., your parents claim
you as a dependent on their tax return). If
you are married, you may claim additional
allowances for your spouse and any dependents that you are entitled to claim for federal
income tax purposes. You also will receive
additional allowances if you or your spouse
are age 65 or older, or if you or your spouse
are legally blind.
How do I figure the correct
number of allowances?
Complete the worksheet on the back of this
page to figure the correct number of allowances you are entitled to claim. Give your
completed Form IL-W-4 to your employer.
Keep the worksheet for your records.
If you have more than one job or your
spouse works, your withholding usually will
be more accurate if you claim all of your allowances on the Form IL-W-4 for the highestpaying job and claim zero on all of your other
IL-W‑4 forms.
How do I avoid underpaying my
tax and owing a penalty?
You can avoid underpayment by reducing the
number of allowances or requesting that your
employer withhold an additional amount from
your pay. Even if your withholding covers
the tax you owe on your wages, if you have
non-wage income that is taxable, such as
interest on a bank account or dividends on
an investment, you may have additional tax
liability. If you owe more than $500 tax at the
end of the year, you may owe a late-payment
penalty or will be required to make estimated
tax payments. For additional information
on penalties see Publication 103, Uniform
Penalties and Interest. Visit our website at
tax.illinois.gov to obtain a copy.
Where do I get help?
• Visit our website at tax.illinois.gov
• Call our Taxpayer Assistance Division at 1 800 732-8866 or 217 782-3336
• Call our TDD (telecommunications device for the deaf) at 1 800 544‑5304
• Write to
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19044
SPRINGFIELD IL 62794-9044
Use your mouse or Tab key to move through the fields. Use your mouse or space bar to enable check boxes.
Illinois Withholding Allowance Worksheet
General Information
Complete this worksheet to figure your total withholding
allowances.
Complete Step 1.
Complete Step 2 if
• you (or your spouse) are age 65 or older or legally blind, or
• you wrote an amount on Line 4 of the Deductions and Adjustments Worksheet for federal Form W-4.
If you have more than one job or your spouse works, your withholding usually will be more accurate if you claim all of your allowances on the Form IL-W-4 for the highest-paying job and claim
zero on all of your other IL-W‑4 forms.
You may reduce the number of allowances or request that your
employer withhold an additional amount from your pay, which may
help avoid having too little tax withheld.
Step
1: Figure your basic personal allowances (including allowances for dependents)
Check all that apply:
No one else can claim me as a dependent.
I can claim my spouse as a dependent.
1 Enter the total number of boxes you checked. 1
_______________
2 Enter the number of dependents (other than you or your spouse) you will claim on your tax return.2 _______________
3 Add Lines 1 and 2. Enter the result. This is the total number of basic personal allowances to which you are
entitled. You are not required to claim these allowances. The number of basic personal allowances that you
choose to claim will determine how much money is withheld from your pay. See Line 4 for more information. 3 _______________
4 Enter the total number of basic personal allowances you choose to claim on this line and Line 1 of
Form IL-W-4 below. This number may not exceed the amount on Line 3 above, however you can claim as
few as zero. Entering lower numbers here will result in more money being withheld(deducted) from your pay. 4 _______________
Step 2: Figure your additional allowances
Check all that apply:
I am 65 or older. I am legally blind.
My spouse is 65 or older. My spouse is legally blind.
5 Enter the total number of boxes you checked. 5 _______________
6 Enter any amount that you reported on Line 4 of the Deductions and Adjustments Worksheet for federal Form W-4 plus any additional Illinois subtractions or deductions.6_______________
7 Divide Line 6 by 1,000. Round to the nearest whole number. Enter the result on Line 7.
7 _______________
8 Add Lines 5 and 7. Enter the result. This is the total number of additional allowances to which you are entitled. You are not required to claim these allowances. The number of additional allowances
that you choose to claim will determine how much money is withheld from your pay.
8 _______________
9 Enter the total number of additional allowances you elect to claim on Line 2 of Form IL-W-4, below. This
number may not exceed the amount on Line 8 above, however you can claim as few as zero. Entering lower
numbers here will result in more money being withheld(deducted) from your pay.
9 _______________
IMPORTANT: If you want to have additional amounts withheld from your pay, you may enter a dollar amount on Line 3 of Form IL-W-4
below. This amount will be deducted from your pay in addition to the amounts that are withheld as a result of the allowances you have
claimed.
Cut here and give the certificate to your employer. Keep the top portion for your records.
Illinois Department of Revenue
IL-W-4 Employee’s Illinois Withholding Allowance Certificate
1 Enter the total number of basic allowances that you
____ ____ ____ - ____ ____ - ____ ____ ____ ____
________________________________________________________________________
Street address
are claiming (Step 1, Line 4, of the worksheet).
1 ____________
2 Enter the total number of additional allowances that
you are claiming (Step 2, Line 9, of the worksheet). 2____________
3 Enter the additional amount you want withheld
(deducted) from each pay.
3 ____________
________________________________________________________________________
CityState
ZIP
I certify that I am entitled to the number of withholding allowances claimed on
this certificate.
Check the box if you are exempt from federal and Illinois
Income Tax withholding and sign and date the certificate.
______________________________________________________________________
Your signature
Date
Social Security number
________________________________________________________________________
Name
IL-W-4 (R-12/14)
This form is authorized under the Illinois Income Tax Act. Disclosure
of this information is required. Failure to provide information may
result in this form not being processed and may result in a penalty.
Reset
Employer: Keep this certificate with your records. If you have referred the employee’s federal
certificate to the IRS and the IRS has notified you to disregard it, you may also be required to
disregard this certificate. Even if you are not required to refer the employee’s federal certificate to
the IRS, you still may be required to refer this certificate to the ­Illinois Department of Revenue for
inspection. See Illinois Income Tax Regulations 86 Ill. Adm. Code 100.7110.
Print
Form WH-4
State Form 48845
(R3 / 5-15)
State of Indiana
Employee’s Withholding Exemption and County Status Certificate
This form is for the employer’s records. Do not send this form to the Department of Revenue.
The completed form should be returned to your employer.
Full Name________________________________________________________ Social Security Number or ITIN___________________________
Home Address_________________________________ City________________________ State_______ Zip Code_______________________
Indiana County of Residence as of January 1:_________________________________________ (See instructions)
Indiana County of Principal Employment as of January 1:________________________________ (See instructions)
___________________________________________________________________________
How to Claim Your Withholding Exemptions
1.You are entitled to one exemption. If you wish to claim the exemption, enter “1”............................................................................... ____________
Nonresident aliens must skip lines 2 through 6. See instructions
2.If you are married and your spouse does not claim his/her exemption, you may claim it, enter “1”.................................................... ____________
3.You are allowed one (1) exemption for each dependent. Enter number claimed................................................................................ ____________
4.Additional exemptions are allowed if: (a) you and/or your spouse are over the age of 65 and/or
(b) if you and/or your spouse are legally blind.
□
□
□
□
or blind
Spouse is 65 or older
or blind
Check box(es) for additional exemptions: You are 65 or older
Enter the total number of boxes checked............................................................................................................................................ ____________
5.Add lines 1, 2, 3, and 4. Enter the total here...................................................................................................................................... ►
6.You are entitled to claim an additional exemption for each qualifying dependent (see instructions)................................................... ►
7.Enter the amount of additional state withholding (if any) you want withheld each pay period............................................................ $___________
8.Enter the amount of additional county withholding (if any) you want withheld each pay period.......................................................... $___________
I hereby declare that to the best of my knowledge the above statements are true.
Signature:_______________________________________________________________________Date:___________________________
Instructions for Completing Form WH-4
This form should be completed by all resident and nonresident employees having income subject to Indiana state and/or county income tax.
Print or type your full name, Social Security number or ITIN and home address. Enter your Indiana county of residence and county of principal employment as of January
1 of the current year. If you neither lived nor worked in Indiana on January 1 of the current year, enter ‘not applicable’ on the line(s). If you move to (or work in) another
county after January 1, your county status will not change until the next calendar tax year.
Nonresident alien limitation. A nonresident alien is allowed to claim only one exemption for withholding tax purposes. If you are a nonresident alien, enter “1” on line
1, then skip to line 7. You are considered to be a nonresident alien if you are not a citizen of the United States and do not meet the green card test and the substantial
presence test (get Publication 519 from www.irs.gov for information about these tests).
All other employees should complete lines 1 through 7.
Lines 1 & 2 - You are allowed to claim one exemption for yourself and one for your spouse (if he/she does not claim the exemption for him/herself). If a parent or legal
guardian claims you on their federal tax return, you may still claim an exemption for yourself for Indiana purposes. You cannot claim more than the correct number of
exemptions; however, you are permitted to claim a lesser number of exemptions if you wish additional withholding to be deducted.
Line 3 - Dependent Exemptions: You are allowed one exemption for each of your dependents based on state and federal guidelines. To qualify as your dependent, a person
must receive more than one-half of his/her support from you for the tax year and must have less than $1,000 gross income during the tax year (unless the person is your
child and is under age 19 or under age 24 and a full-time student at least during 5 months of the tax year at a qualified educational institution).
Line 4 - Additional Exemptions. You are also allowed one exemption each for you and/or your spouse if either is 65 or older and/or blind.
Line 5 - Add the total of exemptions claimed on lines 1, 2, 3, and 4. Enter the total in the box provided.
Line 6 - Additional Dependent Exemptions. An additional exemption is allowed for certain dependent children that are included on line 3. The dependent child must be a
son, stepson, daughter, stepdaughter and/or foster child.
Lines 7 & 8 - If you would like an additional amount to be withheld from your wages each pay period, enter the amount on the line provided. NOTE: An entry on this line
does not obligate your employer to withhold the amount. You are still liable for any additional taxes due at the end of the tax year. If the employer does withhold the additional amount, it should be submitted along with the regular state and county tax withholding.
You may file a new Form WH-4 at any time if the number of exemptions increases. You must file a new Form WH-4 within 10 days if the number of exemptions previously
claimed by you decreases for any of the following reasons:
(a) you divorce (or are legally separated from) your spouse for whom you have been claiming an exemption or your spouse claims him/herself on a separate Form WH-4;
(b) someone else takes over the support of a dependent you claim or you no longer provide more than one-half of the person’s support for the tax year; or
(c) the person who you claim as an exemption will receive more than $1,000 of income during the tax year.
Penalties are imposed for willingly supplying false information or information which would reduce the withholding exemption.
Certificate of Residence
Form WH-47
SF# 9686 (R/12-97)
This form is to be used only by residents of States with a reciprocal tax agreement.*
Indiana Employer's Name
Employer TID Number
Employee Name
Street and City Address
Social Security Number
The employee swears to be a legal resident of the State of
, does not own personal
property in Indiana, and understands that income from salaries, wages, tips and commissions received from Indiana sources
are taxable in their state of residence and not subject to Indiana Adjusted Gross Income Tax as a result of the reciprocal tax
agreement with the State of
. Employee further states the Indiana employer will be advised
of any change in legal residence. Note: The employee understands that the employer remains responsible for withholding
any applicable Indiana County taxes.
Date
,
Employee Signature
Subscribed and sworn to before me, a Notary Public in and for said County and State, this
,
My Commission Expires
.
day of
Notary Public Signature
My County of Residence
Do not send this form to the Indiana Department of Revenue
it is to be filed with and held by the employer.
*States that have reciprocal agreements with Indiana are: Kentucky, Michigan, Ohio, Pennsylvania and Wisconsin.
Revenue Form K-4
42A804 (11-13)
KENTUCKY DEPARTMENT OF REVENUE
EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE
Print Full Name_________________________________________________________________________
Payroll No. __________________________
Social Security No.____________________________
Print Home Address_____________________________________________________________________________________________________________________
HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS
EMPLOYEE:
Failure to file this form with
your employer will result in
withholding tax deductions
from your wages at the
maximum rate. EMPLOYER:
Keep this certificate with
your records.
1. If SINGLE, and you claim an exemption, enter “1,” if you do not, enter “0”..............................................................._________
2. If MARRIED, one exemption each for you and spouse if not claimed on another certificate.
}
(a)If you claim both of these exemptions, enter “2”
(b)If you claim one of these exemptions, enter “1” . ..............................................................................................._________
(c) If you claim neither of these exemptions, enter “0”
3. Exemptions for age and blindness (applicable only to you and your spouse but not to dependents):
(a)If you or your spouse will be 65 years of age or older at the end of the year, and you claim this exemption,
enter “4”; if both will be 65 or older, and you claim both of these exemptions, enter “8”.................................._________
(b)If you or your spouse are blind, and you claim this exemption, enter “4”; if both are blind, and you claim
both of these exemptions, enter “8”.........................................................................................................................._________
4. If you claim exemptions for one or more dependents, enter the number of such exemptions................................._________
5. National Guard exemption (see instruction 1)................................................................................................................_________
6. Exemptions for Excess Itemized Deductions (Form K-4A)............................................................................................._________
7. Add the number of exemptions which you have claimed above and enter the total..................................................
8. Additional withholding per pay period under agreement with employer. See instruction 1...........................$_____________ I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.
Date _________________________________ Signed___________________________________________________________________________________
INSTRUCTIONS
1. NUMBER OF EXEMPTIONS—Do not claim more than the correct
number of exemptions. However, if you have unusually large amounts
of itemized deductions, you may claim additional exemptions to avoid
excess withholding. You may also claim an additional exemption if you
will be a member of the Kentucky National Guard at the end of the year.
If you expect to owe more income tax for the year than will be withheld,
you may increase the withholding by claiming a smaller number of
exemptions or you may enter into an agreement with your employer to
have additional amounts withheld. If you claim more than 10 exemptions
this information is sent to the Department of Revenue.
2. CHANGES IN EXEMPTIONS—You may file a new certificate at
any time if the number of your exemptions INCREASES.
You must file a new certificate within 10 days if the number of
exemptions previously claimed by you DECREASES for any of the
following reasons.
(a) You are divorced or legally separated from your spouse for
whom you have been claiming an exemption or your spouse claims his
or her own exemption on a separate certificate.
(b) The support of a dependent for whom you claimed exemption
is taken over by someone else, so that you no longer expect to furnish
more than half the support for the year.
(c) Your itemized deductions substantially decrease and a Form
K-4A has previously been filed.
OTHER DECREASES in exemption, such as the death of a spouse
or a dependent, do not affect your withholding until the next year, but
require the filing of a new certificate by December 1 of the year in which
they occur.
3. DEPENDENTS—To qualify as your dependent (line 4 on reverse), a person
(a) must receive more than one-half of his or her support from you for the year,
and (b) must not be claimed as an exemption by such person’s spouse, and (c)
must be a citizen of the United States, or a resident of the United States, Canada,
or Mexico, or (d) must have lived with you for the entire year as a member of
your household or be related to you as follows:
your child, stepchild, legally adopted child, foster child (if he lived in your
home as a member of the family for the entire year), grandchild, son-in-law,
or daughter-in-law;
your father, mother, or ancestor of either, stepfather, stepmother, father-inlaw, or mother-in-law;
your brother, sister, stepbrother, stepsister, brother-in-law, or sister-in-law;
your uncle, aunt, nephew, or niece (but only if related by blood).
4. PENALTIES—Penalties are imposed for willfully supplying false information
or willful failure to supply information which would reduce the withholding
exemption.
•
•
•
•
www.revenue.ky.gov
R-1300 (4/11)
Employee Withholding Exemption Certificate (L-4)
Louisiana Department of Revenue
Purpose: Complete form L-4 so that your employer can withhold the correct amount of state income tax from your salary.
Instructions: Employees who are subject to state withholding should complete the personal allowances worksheet indicating the number of withholding
personal exemptions in Block A and the number of dependency credits in Block B.
• Employees must file a new withholding exemption certificate within 10 days if the number of their exemptions decreases, except if the change is the result
of the death of a spouse or a dependent.
• Employees may file a new certificate any time the number of their exemptions increases.
• Line 8 should be used to increase or decrease the tax withheld for each pay period. Decreases should be indicated as a negative amount.
Penalties will be imposed for willfully supplying false information or willful failure to supply information that would reduce the withholding exemption.
This form must be filed with your employer. If an employee fails to complete this withholding exemption certificate, the employer must withhold Louisiana
income tax from the employee’s wages without exemption.
Note to Employer: Keep this certificate with your records. If you believe that an employee has improperly claimed too many exemptions or dependency credits, please
forward a copy of the employee’s signed L-4 form with an explanation as to why you believe that the employee improperly completed this form and any other supporting documentation. The information should be sent to the Louisiana Department of Revenue, Criminal Investigations Division, PO Box 2389, Baton Rouge, LA 70821-2389.
Block A
• Enter “0” to claim neither yourself nor your spouse, and check “No exemptions or dependents claimed” under number 3 below.
You may enter “0” if you are married, and have a working spouse or more than one job to avoid having too little tax withheld.
A.
• Enter “1” to claim yourself, and check “Single” under number 3 below. if you did not claim this exemption in connection with other
employment, or if your spouse has not claimed your exemption. Enter “1” to claim one personal exemption if you will file as head
of household, and check “Single” under number 3 below.
• Enter “2” to claim yourself and your spouse, and check “Married” under number 3 below.
Block B
• Enter the number of dependents, not including yourself or your spouse, whom you will claim on your tax return. If no dependents
are claimed, enter “0.”
B.
Cut here and give the bottom portion of certificate to your employer. Keep the top portion for your records.
Form
L-4
Louisiana
Department of
Revenue
Employee’s Withholding Allowance Certificate
1.Type or print first name and middle initial
Last name
2.Social Security Number
3. Select one
 No exemptions or dependents claimed  Single  Married
4.Home address (number and street or rural route)
5.City
State
ZIP
6.Total number of exemptions claimed in Block A
6.
7. Total number of dependents claimed in Block B
7.
8.Increase or decrease in the amount to be withheld each pay period. Decreases should be indicated as a negative amount. 8.
I declare under the penalties imposed for filing false reports that the number of exemptions and dependency credits claimed on this certificate do not exceed
the number to which I am entitled.
Employee’s signature
Date
The following is to be completed by employer.
9. Employer’s name and address
10. Employer’s state withholding account number
O V I E TE M
BE
AC
RT
PL
AT E
PE TI T
AM
L
I
EN U E
EN SE
ID
EV
M
SACHUSET
AS
M
EN OF R
Social Security no. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
T
City. . . . . . . . . . . . . . . . . . . . . . . State . . . . . . . . . . . . . . . Zip . . . . . . . . . . . . . . . .
T
Print full name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Print home address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Employee:
Rev. 1/12
TS
MASSACHUSETTS EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE
D E PA R
FORM
M-4
SV
B
HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS
File this form or Form W-4 with
your employer. Otherwise,
Massachusetts Income Taxes
will be withheld from your
wages without exemptions.
2. If married and if exemption for spouse is allowed, write the figure “4.” If your spouse is age 65 or over or will
be before next year and if otherwise qualified, write “5.” See Instruction C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........
Employer:
3. Write the number of your qualified dependents. See Instruction D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........
Keep this certificate with your
records. If the employee is
believed to have claimed
excessive exemptions, the
Massachusetts Department
of Revenue should be so
advised.
4. Add the number of exemptions which you have claimed above and write the total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Your personal exemption. Write the figure “1.” If you are age 65 or over or will be before next year, write “2” . . . . . . .
........
5. Additional withholding per pay period under agreement with employer $ _____________________
A.
Check if you will file as head of household on your tax return.
B.
Check if you are blind.
D.
Check if you are a full-time student engaged in seasonal, part-time or temporary employment whose estimated annual income
will not exceed $8,000.
C.
Check if spouse is blind and not subject to withholding.
EMPLOYER: DO NOT withhold if Box D is checked.
I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.
Date. . . . . . . . . . . . . . . . . . . . . . . . . . . Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
THIS FORM MAY BE REPRODUCED
THE COMMONWEALTH OF MASSACHUSETTS, DEPARTMENT OF REVENUE
A. Number. If you claim more than the correct number of exemptions, civil
and criminal penalties may be imposed. You may claim a smaller number of
exemptions. If you do not file a certificate, your employer must withhold on
the basis of no exemptions.
If you expect to owe more income tax than will be withheld, you may either
claim a smaller number of exemptions or enter into an agreement with your
employer to have additional amounts withheld.
You should claim the total number of exemptions to which you are entitled to
prevent excessive overwithholding, unless you have a significant amount of
other income.
If you work for more than one employer at the same time, you must
not claim any exemptions with employers other than your principal
employer.
If you are married and if your spouse is subject to withholding, each may
claim a personal exemption.
B. Changes. You may file a new certificate at any time if the number of
exemptions increases. You must file a new certificate within 10 days if the
number of exemptions previously claimed by you decreases. For example,
if during the year your dependent son’s income indicates that you will not
provide over half of his support for the year, you must file a new certificate.
C. Spouse. If your spouse is not working or if she or he is working but not
claiming the personal exemption or the age 65 or over exemption, generally you may claim those exemptions in line 2. However, if you are planning to
file separate annual tax returns, you should not claim withholding exemptions for your spouse or for any dependents that will not be claimed on your
annual tax return.
If claiming a wife or husband, write “4” in line 2. Using “4” is the withholding
system adjustment for the $4,400 exemption for a spouse.
D. Dependent(s). You may claim an exemption in line 3 for each individual
who qualifies as a dependent under the Federal Income Tax Law. In addition,
if one or more of your dependents will be under age 12 at year end, add “1”
to your dependents total for line 3.
You are not allowed to claim “federal withholding deductions and
adjustments” under the Massachusetts withholding system.
If you have income not subject to withholding, you are urged to have
additional amounts withheld to cover your tax liability on such income.
See line 5.
IF THE ALLOWABLE MASSACHUSETTS WITHHOLDING EXEMPTIONS ARE THE SAME
AS YOU ARE CLAIMING FOR U.S. INCOME TAXES, COMPLETE U.S. FORM W-4 ONLY.
MARYLAND
FORM
MW507
Purpose. Complete Form MW507 so that your employer can withhold the correct
Maryland income tax from your pay. Consider completing a new Form MW507
each year and when your personal or financial situation changes.
Basic Instructions. Enter on line 1 below, the number of personal exemptions
you will claim on your tax return. However, if you wish to claim more exemptions,
or if your adjusted gross income will be more than $100,000 if you are filing
single or married filing separately ($150,000, if you are filing jointly or as head
of household), you must complete the Personal Exemption Worksheet on page
2. Complete the Personal Exemption Worksheet on page 2 to further adjust your
Maryland withholding based on itemized deductions, and certain other expenses
that exceed your standard deduction and are not being claimed at another job or
by your spouse. However, you may claim fewer (or zero) exemptions.
Additional withholding per pay period under agreement with employer. If
you are not having enough tax withheld, you may ask your employer to withhold
more by entering an additional amount on line 2.
Exemption from withholding. You may be entitled to claim an exemption from
the withholding of Maryland income tax if:
a.Last year you did not owe any Maryland Income tax and had a right to a full
refund of any tax withheld; AND,
b. This year you do not expect to owe any Maryland income tax and expect to have
a right to a full refund of all income tax withheld.
If you are eligible to claim this exemption, complete Line 3 and your employer will
not withhold Maryland income tax from your wages.
Students and Seasonal Employees whose annual income will be below the minimum filing requirements should claim exemption from withholding. This provides
more income throughout the year and avoids the necessity of filing a Maryland
income tax return.
Certification of nonresidence in the State of Maryland. Complete Line 4. This
line is to be completed by residents of the District of Columbia, Virginia or West
Virginia who are employed in Maryland and who do not maintain a place of abode
in Maryland for 183 days or more.
Residents of Pennsylvania who are employed in Maryland and who do not maintain
a place of abode in Maryland for 183 days or more, should complete line 5 to exempt themselves from the state portion of the withholding tax. These employees
are still liable for withholding tax at the rate in effect for the Maryland county in
which they are employed, unless they qualify for an exemption on either line 6 or
line 7. Pennsylvania residents of York and Adams counties may claim an exemption from the local withholding tax by completing line 6. Pennsylvania residents
living in other local jurisdictions which do not impose an earnings or income tax
on Maryland residents may claim an exemption by completing line 7. Employees
qualifying for exemption under 6 or 7, should also write “EXEMPT” on line 4.
Line 4 is NOT to be used by residents of other states who are working in Maryland,
because such persons are liable for Maryland income tax and withholding from
FORM
MW507
their wages is required.
If you are domiciled in the District of Columbia, Pennsylvania or Virginia and maintain a place of abode in Maryland for 183 days or more, you become a statutory
resident of Maryland and you are required to file a resident return with Maryland
reporting your total income. You must apply to your domicile state for any tax
credit to which you may be entitled under the reciprocal provisions of the law. If
you are domiciled in West Virginia, you are not required to pay Maryland income
tax on wage or salary income, regardless of the length of time you may have
spent in Maryland.
Under the Servicemembers Civil Relief Act, as amended by the Military Spouses
Residency Relief Act, you may be exempt from Maryland income tax on your
wages if (i) your spouse is a member of the armed forces present in Maryland in
compliance with military orders; (ii) you are present in Maryland solely to be with
your spouse; and (iii) you maintain your domicile in another state. If you claim
exemption under the SCRA enter your state of domicile (legal residence) on Line
8; enter “EXEMPT” in the box to the right on Line 8; and attach a copy of your
spousal military identification card to Form MW507. In addition, you must also
complete and attach Form MW507M.
Duties and responsibilities of employer. Retain this certificate with your records. You are required to submit a copy of this certificate and accompanying
attachments to the Compliance Division, Compliance Programs Section, 301 West
Preston Street, Baltimore, MD 21201, when received if:
1.You have any reason to believe this certificate is incorrect;
2.The employee claims more than 10 exemptions;
3.The employee claims an exemption from withholding because he/she had no
tax liability for the preceding tax year, expects to incur no tax liability this year
and the wages are expected to exceed $200 a week;
4.The employee claims an exemption from withholding on the basis of nonresidence; or
5.The employee claims an exemption from withholding under the Military Spouses Residency Relief Act.
Upon receipt of any exemption certificate (Form MW507), the Compliance Division
will make a determination and notify you if a change is required.
Once a certificate is revoked by the Comptroller, the employer must send any new
certificate from the employee to the Comptroller for approval before implementing
the new certificate.
If an employee claims exemption under 3 above, a new exemption certificate must
be filed by February 15th of the following year.
Duties and responsibilities of employee. If, on any day during the calendar
year, the number of withholding exemptions that the employee is entitled to claim
is less than the number of exemptions claimed on the withholding exemption certificate in effect, the employee must file a new withholding exemption certificate
with the employer within 10 days after the change occurs.
Employee’s Maryland Withholding Exemption Certificate
Print full name
Social Security Number
Street Address, City, State, ZIP
County of residence (Nonresidents enter Maryland county (or Baltimore City) where you are employed.)
Single
Married (surviving spouse or unmarried Head of Household) Rate
Married, but withhold at Single rate
1. Total number of exemptions you are claiming not to exceed line f in Personal Exemption Worksheet on page 2. . . . . . . . . . . . . . . . . . . . . . . . 1._______________
2. Additional withholding per pay period under agreement with employer.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2._______________
3. I claim exemption from withholding because I do not expect to owe Maryland tax. See instructions above and check boxes that apply.
a. Last year I did not owe any Maryland income tax and had a right to a full refund of all income tax withheld and
b. This year I do not expect to owe any Maryland income tax and expect to have the right to a full refund of all income tax withheld.
(This includes seasonal and student employees whose annual income will be below the minimum filing requirements).
If both a and b apply, enter year applicable _____________ (year effective) Enter “EXEMPT” here . . . . . . . . . . . . . . . . . . . . . . . . . . 3._______________
4. I claim exemption from withholding because I am domiciled in one of the following states. Check state that applies.
District of Columbia
Virginia
West Virginia
I further certify that I do not maintain a place of abode in Maryland as described in the instructions above. Enter “EXEMPT” here. . . . . . . . . . . 4._______________
5. I claim exemption from Maryland state withholding because I am domiciled in the Commonwealth of Pennsylvania and I do not
maintain a place of abode in Maryland as described in the instructions on Form MW507. Enter “EXEMPT” here.. . . . . . . . . . . . . . . . . . . . . . . 5._______________
6. I claim exemption from Maryland local tax because I live in a local Pennysylvania jurisdiction within York or Adams counties.
Enter “EXEMPT” here and on line 4 of Form MW507.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6._______________
7. I claim exemption from Maryland local tax because I live in a local Pennsylvania jurisdiction that does not impose an earnings or income
tax on Maryland residents. Enter “EXEMPT” here and on line 4 of Form MW507. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7._______________
8. I certify that I am a legal resident of the state of ____________ and am not subject to Maryland withholding because l meet the requirements set forth under the Servicemembers Civil Relief Act, as amended by the Military Spouses Residency Relief Act. Enter “EXEMPT” here.. . . 8._______________
Under the penalty of perjury, I further certify that I am entitled to the number of withholding allowances claimed on line 1 above, or if claiming exemption
from withholding, that I am entitled to claim the exempt status on whichever line(s) I completed.
Employee’s signature
Date
Employer’s name and address including ZIP code (For employer use only)
Federal Employer Identification Number
COM/RAD-03616-49
page 2
MARYLAND
FORM
MW507
Personal Exemptions Worksheet
Line 1
a. Multiply the number of your personal exemptions by the value of each exemption from the table below.
(Generally the value of your exemption will be $3,200; however, if your federal adjusted gross income is
expected to be over $100,000, the value of your exemption may be reduced. Do not claim any personal
exemptions you currently claim at another job, or any exemptions being claimed by your spouse.
To qualify as your dependent, you must be entitled to an exemption for the dependent on your federal
income tax return for the corresponding tax year. NOTE: Dependent taxpayers may not claim themselves as
an exemption.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a. ______________ b. Multiply the number of additional exemptions you are claiming for dependents 65 years old or older by the
value of each exemption from the table below. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. ______________ c. Enter the estimated amount of your itemized deductions (excluding state and local income taxes) that
exceed the amount of your standard deduction, alimony payments, allowable childcare expenses, qualified
retirement contributions, business losses and employee business expenses for the year. Do not claim any
additional amounts you currently claim at another job or any amounts being claimed by your spouse.
NOTE: Standard deduction allowance is 15% of Maryland adjusted gross income with a minimum of $1,500
and a maximum of $2,000.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c. ______________
d. Enter $1,000 for additional exemptions for taxpayer and/or spouse at least 65 years old and/or blind. . . . . . d. ______________
e. Add total of lines a through d.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e. ______________
f. Divide the amount on line e by $3,200. Drop any fraction. Do not round up. This is the maximum
number of exemptions you may claim for withholding tax purposes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . f. ______________
If you will file your tax return
If Your federal AGI is
$100,000 or less
Single or Married Filing Separately
Your Exemption is
Joint, Head of Household
or Qualifying Widow(er)
Your Exemption is
$3,200
$3,200
Over
But not over
$100,000
$125,000
$1,600
$3,200
$125,000
$150,000
$800
$3,200
$150,000
$175,000
$0
$1,600
$175,000
$200,000
$0
$800
$0
$0
In excess of $200,000
FEDERAL PRIVACY ACT INFORMATION
Social Security Numbers must be included. The mandatory disclosure of your Social Security Number is
authorized by the provisions set forth in the Tax-General Article of the Annotated Code of Maryland. Such
numbers are used primarily to administer and enforce the individual income tax laws and to exchange
income tax information with the Internal Revenue Service, other states and other tax officials of this state.
Information furnished to other agencies or persons shall be used solely for the purpose of administering tax
laws or the specific laws administered by the person having statutory right to obtain it.
COM/RAD-03616-49
MAINE
FORM
W-4ME
1.
Employee’s Withholding Allowance Certificate
Type or print your First Name
M.I.
Last Name
2. Your Social Security Number
-
Home address (number and street or rural route)
City or town
3.
State
Single
Married
Married, but withholding at higher single rate
ZIP Code
Note: If married but legally separated, or spouse is a nonresident
alien, check the single box.
4.
Total number of allowances you are claiming from line C of the personal allowances worksheet below ..................... 4.
5.
Additional amount, if any, you want withheld from your paycheck ................................................................................ 5.
6.
If you do not want any state income tax withheld, check the appropriate box that applies to you (you must qualify - see instructions below). By
signing below, you certify that you qualify for the exemption that you select:
$
a.
You claimed “Exempt” on line 7 of your federal Form W-4 .................................................................................................................. 6a.
b.
You completed federal Form W-4P and checked the box on line 1 .................................................................................................... 6b.
c.
You are a resident employee with no Maine tax liability in prior or current year ................................................................................. 6c.
d.
e.
You are a recipient of periodic retirement payments with no tax liability in prior or current year ........................................................ 6d.
Your spouse is a member of the military assigned to a location in Maine and you qualify for exemption under the Military
Spouse’s Residency Relief Act. You must attach supporting documents. See instructions.............................................................. 6e.
Under penalties of perjury, I certify that I am entitled to the number of withholding allowances or the exemption claimed on this certificate.
EMPLOYEE’S/PAYEE’S SIGNATURE
(Form is not valid
unless you sign it.)
Date
TO BE COMPLETED BY EMPLOYER/PAYER (see Instructions)
7. Employer/Payer Name and Address (Employer/Payer: Complete lines 7, 8, 9, and 10 only if sending to Maine
8. Identification Number
Revenue Services)
9. Employer/Payer Contact Person:
10. Contact Person’s Phone Number:
(
____________
(
Cut here and give the certificate above to your employer. Keep the part below for your records.
____________
Personal Allowances Worksheet - for line 4 above
A. Number of allowances claimed on federal Form W-4, line 5 or Form W-4P, line 2. ................................................................A. _________________
B. Less: Number of allowances claimed on federal Form W-4 Personal Allowances Worksheet,
line G for the Child Tax Credit..................................................................................................................................................B. _________________
C. Maximum number of allowances for Maine purposes (line A minus line B). Enter here and on line 4 above. See line 4
instructions below if you want to claim fewer allowances or more allowances than claimed for federal purposes. ................C. _________________
Employee/Payee Instructions
Purpose: Complete Form W-4ME so your employer/payer can withhold the
correct Maine income tax from your pay. Because your tax situation may
change, you may want to recalculate your withholding each year.
Line 4. If you qualify for one of the Maine exemptions from withholding,
please complete lines 1, 2, 3 and 6, and sign the form. Otherwise, complete
the Personal Allowances worksheet above. You may claim fewer allowances
than you are entitled to, but you must obtain special permission from the
State Tax Assessor if you want to claim more allowances than claimed on
your federal Form W-4.
Box 3. Select the marital status that applies to you. You must select the
same marital status you selected on your federal Form W-4, except that
married individuals have the option of withholding at the higher single rate.
Nonresident aliens are required to check the single box regardless of actual
marital status.
Line 6. Exemptions from withholding:
Line 6a. You may check this box if you claimed “Exempt” on line 7 of your
federal Form W-4. Do not check this box if you want Maine income taxes
withheld even though you are exempt from federal withholding.
Line 6b. You may check this box if you completed federal Form W-4P
and put a check in the box on line 1. Do not check this box if you want
Maine income taxes withheld even though you are exempt from federal
withholding.
Line 6c. You may elect this exemption if you are an employee receiving
wages and you meet both of the following conditions:
1. You had no Maine income tax liability last year , and
2. You reasonably expect to have no Maine income tax liability this
year.
This exemption will expire at the end of the year and you must complete a
new Form W-4ME for next year or you will be subject to Maine withholding
at the maximum rate.
Line 6d. You may elect this exemption if you receive periodic retirement
payments pursuant to IRC § 3405, you had no Maine income tax liability in
the prior year and you reasonably expect you will have no Maine income tax
liability this year. This election will remain in effect until you complete a new
Form W-4ME.
instructions continued on next page
Line 6e. If you are the spouse of a member of the military, you may claim
exemption from Maine withholding if you meet the following requirements:
1. Your spouse is a member of the military located in Maine in compliance
with military orders.
2. You are in Maine solely to be with your spouse.
3. You and your spouse have the same domicile in a state other than Maine.
4. You attach a copy of your spouse’s latest Leave and Earning Statement
reflecting an assignment location in Maine.
5. You present your military ID to your employer. The ID must identify
you as a military spouse.
Your exemption will expire at the end of the calendar year during which
you submit Form W-4ME claiming the exemption, at which time you must
complete and submit a new Maine Form W-4ME for the new year.
Note: You may be subject to penalty if you do not have sufficient withholding
to meet your Maine income tax liability.
Notice to Employers and Other Payers
Maine law requires employers and other persons to withhold money from certain payments, most commonly wages, retirement payments and
gambling winnings, and remit to Maine Revenue Services for application against the Maine income tax liability of employees and other payees.
The amount of withholding must be calculated according to the provisions of Rule No. 803 (See www.maine.gov/revenue/rules) and must
constitute a reasonable estimate of Maine income tax due on the receipt of the payment. Amounts withheld must be paid over to Maine Revenue
Services on a periodic basis as provided by Title 36 M.R.S.A. Chapter 827 ( §§ 5250 - 5255-B) and Rule No. 803 (18-125 CMR 803).
Employer/Payer Information for Completing Form W-4ME
An employer/payer is required to submit a copy of Form W-4ME, along with a copy of any supporting information provided by the employee/payee, to
Maine Revenue Services if:
A. The employer/payer is required to submit a copy of federal Form W-4 to the Internal Revenue Service either by written notice or by published
guidance as required by federal regulation 26 CFR 31.3402(f)(2)-1(g); or
B. An employee performing personal services in Maine furnishes a Form W-4ME to the employer containing a non-Maine address and for any reason
claims no Maine income tax is to be withheld. This submission is not required if the employer reasonably expects that the employee will earn annual
Maine-source income of less than $5,000 or if the employee is a nonresident working in Maine for no more than 10 days for the calendar year and
is, therefore, exempt from Maine income tax withholding pursuant to MRS Rule 803 Section 3.1.I.1.
Submit copies of Form W-4ME directly to the MRS Withholding Unit separately from any other tax filing.
Employers/Payers must complete lines 7 through 10 only if required to submit a copy of Form W-4ME to Maine Revenue Services (“MRS”).
Line 7
Enter employer/payer name and business address.
Line 8
Enter employer/payer federal identification number (EIN and/or SSN).
Line 9
Enter employer/payer contact person that can answer questions about withholding (i.e. human resources person, company officer,
accountant, etc.)
Line 10
Enter employer/payer contact person’s phone number.
Important Information for Employers/Payers
Missing or invalid Forms W-4, W-4P or W-4ME. If any of the circumstances below occur, the employer or payer must withhold as if the employee or
payee were single and claiming no allowances. Maine income tax must be withheld at this rate until such time that the employee or payee provides a valid
Form W4-ME.
(1) The employee/payee has not provided a valid, signed Form W-4ME;
(2) The employee’s/payee’s Form W-4 or W-4P is determined to be invalid for purposes of federal withholding;
(3) The assessor notifies the employer/payer that the employee’s/payee’s Form W-4ME is invalid; or
(4) The employee’s/payee’s Personal Withholding Allowance Variance Certificate has expired, a new variance certificate has not been approved and
submitted to the employer/payer, and the payee has not provided the payer with a valid Form W-4ME.
Exemptions from withholding Form W-4ME, line 6. Generally, employers/payers must withhold from payments subject to Maine income tax unless an
exemption is indicated on Form W-4ME, line 6.
Federal exemption from withholding (see Form W-4ME, lines 6a and 6b). An employee/payee who is exempt from federal income tax withholding
is also exempt from Maine income tax withholding. This includes recipients of periodic retirement payments who are exempt from federal income tax
withholding. The employee/payee must check the applicable box on Form W-4ME, line 6. An employee/payee exempt from federal withholding that
wants Maine withholding must leave line 6 blank.
Resident employee exemption from Maine withholding (see Form W-4ME, line 6c). A resident employee who is subject to federal income tax
withholding is exempt from Maine income tax withholding if the employee had no Maine tax liability for the prior year and expects to have no Maine tax
liability for the current year. The exemption indicated on line 6c expires at the end of each year. If the employee fails to submit a new Form W-4ME for
the next calendar year, the employer must begin withholding at the single rate with no allowances.
Withholding from payments to nonresident employees. An employee who is exempt from Maine income tax because of the nontaxable thresholds
applicable to nonresidents is not required to complete and submit Form W-4ME; however, an employee becomes subject to Maine income tax withholding
immediately upon exceeding the 10-day threshold at any time during the year. Because income earned during the first 10 days worked in Maine is
taxable by Maine once the threshold is exceeded, employers should work with affected employees to ensure that Maine withholding is adequate to cover
Maine income tax liability for the year. This may require the employee submitting a new Form W-4ME with the employer.
Withholding exemption for periodic retirement payments (see Form W-4ME, line 6d). Recipients of periodic retirement payments as defined by IRC
§ 3405 that are subject to federal income tax withholding are exempt from Maine income tax withholding if the recipient certifies (by checking the box
on line 6c) that he or she had no Maine income tax liability for the prior year and expects to have no Maine income tax liability for the current year. The
exemption remains in effect until the recipient submits an updated Form W-4ME.
Exemptions under the Military Spouse’s Residency Relief Act (MSRRA). If the box on line 6e is checked, the employer must:
(1) Ensure that a copy of the military member’s Leave and Earnings Statement (LES) is attached, and verify that the assignment location entered
on the LES is a location in Maine; and
(2) Review the employee’s military ID to ensure that the date on the ID is not more than four years prior to the date on the employee’s Form W-4ME,
and that the ID denotes the employee as a current military spouse.
An exemption claimed on line 6e expires at the end of the calendar year. If the employee does not submit a new Maine Form W-4ME, the employer must
begin withholding for the first pay period in the following year at the maximum rate (single with one allowance).
See the employee instructions for line 6e above for more information about this exemption.
Rev. 01/11
Reset Form
MI-W4
(Rev. 8-08)
EMPLOYEE'S MICHIGAN WITHHOLDING EXEMPTION CERTIFICATE
STATE OF MICHIGAN - DEPARTMENT OF TREASURY
This certificate is for Michigan income tax withholding purposes only. You must file a revised form within 10 days if your exemptions decrease or your residency status changes
from nonresident to resident. Read instructions below before completing this form.
1. Social Security Number
2. Date of Birth
Issued under P.A. 281 of 1967.
3. Type or Print Your First Name, Middle Initial and Last Name
4. Driver License Number
Home Address (No., Street, P.O. Box or Rural Route)
5. Are you a new employee?
Yes
City or Town
State
If Yes, enter date of hire . . . .
ZIP Code
No
6. Enter the number of personal and dependent exemptions you are claiming
6.
7. Additional amount you want deducted from each pay
.00
(if employer agrees)
7. $
8. I claim exemption from withholding because (does not apply to nonresident members of flow-through entities - see instructions):
a.
A Michigan income tax liability is not expected this year.
b.
Wages are exempt from withholding. Explain: _______________________________________________________
c.
Permanent home (domicile) is located in the following Renaissance Zone: _________________________________
EMPLOYEE:
If you fail or refuse to file this form, your
employer must withhold Michigan income tax
from your wages without allowance for any
exemptions. Keep a copy of this form for your
records.
Under penalty of perjury, I certify that the number of withholding exemptions claimed on this certificate does not
exceed the number to which I am entitled. If claiming exemption from withholding, I certify that I anticipate that I
will not incur a Michigan income tax liability for this year.
9. Employee's Signature
Date
Employer: Complete lines 10 and 11 before sending to the Michigan Department of Treasury.
INSTRUCTIONS TO EMPLOYER:
Employers must report all new hires to the State 10. Employer's Name, Address, Phone No. and Name of Contact Person
of Michigan. Keep a copy of this certificate with
your records. If the employee claims 10 or more
personal and dependent exemptions or claims a
status
exempting
the
employee
from
withholding, you must file their original MI-W4
11. Federal Employer Identification Number
form with the Michigan Department of Treasury.
Mail to: New Hire Operations Center, P.O. Box
85010; Lansing, MI 48908-5010.
INSTRUCTIONS TO EMPLOYEE
You must submit a Michigan withholding exemption
certificate (form MI-W4) to your employer on or before the date
that employment begins. If you fail or refuse to submit this
certificate, your employer must withhold tax from your
compensation without allowance for any exemptions. Your
employer is required to notify the Michigan Department of
Treasury if you have claimed 10 or more personal and
dependent exemptions or claimed a status which exempts you
from withholding.
If you hold more than one job, you may not claim the same
exemptions with more than one employer. If you claim the
same exemptions at more than one job, your tax will be under
withheld.
Line 7: You may designate additional withholding if you expect
to owe more than the amount withheld.
Line 6: Personal and dependent exemptions. The total number
of exemptions you claim on the MI-W4 may not exceed the
number of exemptions you are entitled to claim when you file
your Michigan individual income tax return.
Line 8: You may claim exemption from Michigan income tax
withholding ONLY if you do not anticipate a Michigan income
tax liability for the current year because all of the following
exist: a) your employment is less than full time, b) your
personal and dependent exemption allowance exceeds your
annual compensation, c) you claimed exemption from federal
withholding, d) you did not incur a Michigan income tax liability
for the previous year. You may also claim exemption if your
permanent home (domicile) is located in a Renaissance Zone.
Members of flow-through entities may not claim exemption
from nonresident flow-through withholding. For more
information on Renaissance Zones call the Michigan Tele-Help
System, 1-800-827-4000. Full-time students that do not satisfy
all of the above requirements cannot claim exempt status.
If you are married and you and your spouse are both
employed, you both may not claim the same exemptions with
each of your employers.
Web Site
Visit the Treasury Web site at:
www.michigan.gov/businesstax
You MUST file a new MI-W4 within 10 days if your residency
status changes or if your exemptions decrease because: a)
your spouse, for whom you have been claiming an exemption,
is divorced or legally separated from you or claims his/her own
exemption(s) on a separate certificate, or b) a dependent must
be dropped for federal purposes.
Line 5: If you check "Yes," enter your date of hire
(mo/day/year).
Form CF-W-4 — EMPLOYEE’S WITHHOLDING CERTIFICATE
FOR MICHIGAN CITIES LEVYING AN INCOME TAX (See list below)
Revised 12/02/2014
1. Print your full name
Social Security No.
2. Address, Number and Street
EMPLOYEE: File this form with your
employer. Otherwise your employer must
withhold tax for the cities without any allowance
for exemptions.
Apartment
Employee Identification No
City, Township or Village where you reside
State
EMPLOYER: Keep this certificate with your records. If the
YOUR WITHHOLDING EXEMPTIONS
information submitted by the employee is not believed to be true,
4.
Exemptions
for yourself (See cities below)
correct and complete, the City Income Tax Department must be
advised.
5. Exemptions for spouse (See cities below)
CHECK BOX IF
CHECK BOX
YOU ARE A
MICHIGAN CITIES
IF YOU ARE A NONRESIDENT
LEVYING AN INCOME
RESIDENT OF
AND WORK
TAX AND THE VALUE
A LISTED
FOR
OF ONE EXEMPTION
CITY
EMPLOYER IN
A LISTED CITY
CHECK THE BOX THAT INDICATES THE
APPROXIMATE AMOUNT OF TIME WORKING
FOR EMPLOYER IN THE CHECKED
NONRESIDENT CITY
UNDER
25%
25%
TO
40%
41%
TO
60%
61%
TO
80%
81%
TO
100%
6. Exemptions for your dependent children
Nonresident City
Exemptions
4
5
6
7
8. Total number of exemptions claimed
8
Exemptions allowed by city for taxpayer and spouse, if married.
Regular
exemption
4. Taxpayer
5. Spouse
Battle Creek
$750
4. Taxpayer
5. Spouse
Big Rapids
$600
4. Taxpayer
5. Spouse
Detroit
$600
4. Taxpayer
5. Spouse
Flint
$600
4. Taxpayer
5. Spouse
Grand Rapids
$600
4. Taxpayer
5. Spouse
Grayling
$3,000
4. Taxpayer
5. Spouse
Hamtramck
$600
4. Taxpayer
5. Spouse
Highland Park
$600
4. Taxpayer
5. Spouse
Hudson
$1,000
4. Taxpayer
5. Spouse
Ionia
$700
4. Taxpayer
5. Spouse
Jackson
$600
4. Taxpayer
5. Spouse
Lansing
$600
4. Taxpayer
5. Spouse
Lapeer
$600
4. Taxpayer
5. Spouse
Muskegon
$600
4. Taxpayer
5. Spouse
Muskegon Heights
$600
4. Taxpayer
5. Spouse
Pontiac
$600
4. Taxpayer
5. Spouse
Port Huron
$600
4. Taxpayer
5. Spouse
Portland
$1,000
4. Taxpayer
5. Spouse
Saginaw
$750
4. Taxpayer
5. Spouse
Springfield
$750
4. Taxpayer
5. Spouse
Walker
$600
4. Taxpayer
5. Spouse
9. Date
Postal Code
Resident City
Exemptions
7. Exemptions for your other dependents
Albion
$600
I am not a resident
of any listed city
I do not expect to
work in any city listed
Office, Plant, Dept.
10. Signature
65 or over at end
of year
Blind
Deaf
Permanently
Disabled
Form LW-4 Instructions
Purpose: Complete form LW-4 so your employer can withhold the correct amount of city income taxes from your pay.
Dependents: To qualify as your dependent (line 4 below), a person
(a) Must receive more than one-half of his or her support from you for the year, and
(b) Must have less than $600 gross income during the year (except your child who is a student or who is under 19
years of age, and
(c) Must not be claimed as an exemption by such person’s husband or wife, and
(d) Must be a citizen or resident of the United States, and
(e) Must have your home as his/her principal residence and be a member of your household for the entire year, or
Must be related to you as follows: Your son or daughter, grandchild, step-son/daughter, son/daughter-in-law,
father, mother, grandparent, step-father/mother, father/mother-in-law, brother, sister, stepbrother/sister, half
brother/sister, brother/sister-in-law, uncle, aunt, nephew, or niece (but only if related by blood).
Changes in exemptions: You must file a new certificate within 10 days if the number of exemptions previously claimed
by you decreases for any of the following reasons:
(a) Your wife/husband for whom you have been claiming exemption is divorced or legally separated, or claims her/his
own exemption on a separate certificate.
(b) The support of a dependent for whom you claimed exemption is taken over by someone else.
(c) You find that a dependent for whom you claimed exemption will receive $600 or more income of his/her own
during the year (except your child who is a student and who is under 19 years of age).
Other Decreases: Such as the death of a wife, husband, or a dependent, do not affect your withholding until the next
year, but require the filing of a new certificate by December 1 of the year in which they occur.
Change of Residence: You must file a new certificate within 10 days after you change your residence from or to a
taxing city.
Employee: File this form with your employer. Otherwise your employer must withhold City of Lansing income tax from
your earnings without exemptions.
Employer: Keep this certificate with your record. If the information submitted by the employee is not believed to be true,
correct and complete the City of Lansing must be advised.
FORM LW-4
EMPLOYEE’S WITHHOLDING CERTIFICATE FOR
CITY OF LANSING INCOME TAX
Your Social Security Number:
City Resident or
Non-City Resident
Full Name: (First, Middle and Last Name)
Home Address: (Number & Street)
City:
State:
1. Exemptions for yourself:
Zip Code:
3. Enter Total number of
boxes checked in 1& 2:
2. Exemptions for your spouse:
Yourself
age 65 or over
Blind
Yourself
age 65 or over
Blind
4. Other Exemptions:
5. Enter total number of Other Exemptions
Number of exemptions
Number of exemptions
in box 4 below:
for your children
for your other dependents
6. Add the number of exemptions which you have 7. Write the additional amounts you want withheld from each
claimed in box 3 & 5 and write the total below:
paycheck, if any:
Employer’s Name and Address:
I certify that the information submitted on this certificate is true, correct and complete to the best of my knowledge and belief.
SIGNATURE:
DATE:
W-4MN
2016 Minnesota Employee Withholding Allowance/Exemption
Certificate
Employees
You must complete and give this form to your employer if you:
• claim fewer Minnesota withholding allowances than your federal allowances;
• claim more than 10 Minnesota withholding allowances;
• want additional Minnesota tax withheld from your pay each pay period; or
• claim to be exempt from federal withholding or claim to be exempt from Minnesota withholding.
Do not complete this form if you are claiming the same number of Minnesota allowances as federal and the number claimed is 10 or less.
Employee
Information
Employee’s first name and initial
Last name
Employee’s Social Security number
Permanent address
City
State
ZIP code
Marital status (check one box)
Single; Married, but legally separated; or
Spouse is a nonresident alien
Married
Minnesota
Allowances
Married, but withhold at higher Single rate
Employees: Read instructions on back, complete Section 1 OR Section 2, sign and give the completed form to your employer.
(Do not complete both Section 1 and Section 2. Completing both sections will make the form invalid.)
Section 1 — Determining Minnesota allowances
Complete Section 1 if you claim fewer Minnesota allowances than your federal allowances, AND/OR if you want additional Minnesota withholding deducted each pay period.
1 Total number of federal allowances claimed on federal Form W-4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Total number of Minnesota allowances (line 2 cannot be more than line 1) . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Additional Minnesota withholding you want deducted each pay period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3$
Exempt from
Minnesota Withholding
Section 2 — Exemption from Minnesota withholding
Complete Section 2 if you claim to be exempt from Minnesota income tax withholding (see Section 2 instructions for qualifications). If applicable, check one box below to indicate the reason why you believe you are exempt:
I meet the requirements and claim exempt from both federal and Minnesota income tax withholding.
Even though I did not claim exempt from federal withholding, I claim exempt from Minnesota withholding because I had no
Minnesota income tax liability last year, I received a refund of all Minnesota income tax withheld, AND I expect to have no Minnesota income tax liability this year.
My spouse is a military service member assigned to a military location in Minnesota, my domicile (legal residence) is in another
state, AND I am in Minnesota solely to be with my spouse. My state of domicile is
.
I am an American Indian living and working on a reservation.
Sign
Here
I am a member of the Minnesota National Guard or an active duty U.S. military member and claim exempt from Minnesota
withholding on my military pay.
I certify that all information provided in Section 1 OR Section 2 is correct. I understand there is a $500 penalty for filing a false withholding allowance/exemption certificate.
Employee’s signature
Date
Daytime phone
Employees: Give the completed form to your employer.
Employers
If you are required to send a copy of this form to the Department of Revenue (see instructions), you must enter the employer information below
and mail this form to: Minnesota Revenue, Mail Station 6501, St. Paul, MN 55146-6501. (Incomplete forms are considered invalid.) A $50
penalty may be assessed for each required Form W-4MN not filed with the department.
Employer
Information
Keep a copy for your records.
(Rev. 12/15)
Name of employer
Address
Questions?
Federal employer ID number (FEIN)
City
State
Minnesota tax ID number
ZIP code
Website: www.revenue.state.mn.us. Email: [email protected]. Phone: 651-282‑9999 or 1-800-657-3594.
Form W-4MN Instructions
Do not complete this form if you are claiming the same number of Minnesota allowances as federal and the number
claimed is 10 or less.
Employee Instructions
Should I complete Form W-4MN?
Complete Form W-4MN and provide it to
your employer, if you:
• claim fewer Minnesota allowances than
federal allowances (You may not claim
more Minnesota allowances than federal
allowances);
• claim more than 10 Minnesota allowances;
• request additional Minnesota withholding be deducted each pay period; or
• claim to be exempt from Minnesota
income tax withholding (see Section 2
instructions).
Before you complete Form W-4MN, determine the number of federal withholding
allowances you are claiming on federal Form
W-4. Then, determine the number of your
Minnesota withholding allowances.
Consider completing a new Form W-4MN if
your personal or financial situation changes.
If you have not had sufficient income tax
withheld from your wages, interest and/or
penalty charges may be assessed when you
file your individual income tax return.
Your employer may be required to submit
copies of your Form W-4MN to the department.
Note: You may be subject to a $500 penalty
if you submit a false Form W-4MN.
Section 1 — Minnesota Allowances
Claim the correct number of allowances. If
you expect to owe more income tax for the
year than will be withheld:
• claim fewer allowances; or
• request additional Minnesota taxes to be
withheld from your wages (complete line
3).
Section 2 — Minnesota Exemption
Your employer will not withhold Minnesota
taxes from your pay if you are exempt from
withholding. To claim exemption, you must
meet one of the following requirements:
• You meet the federal requirements; you
claim exempt from federal withholding
on Form W-4; you had no Minnesota
income tax liability in the prior year; you
received a full refund of Minnesota tax
withheld; and you expect to have no Minnesota income tax liability for the current
year. OR
• You are the spouse of a military member
assigned to duty in Minnesota, you and
your spouse are domiciled in another
state (the same state as one another) and
are present in Minnesota solely to be with
your active duty military member spouse.
OR
Note: In order to avoid owing tax at the end
of the year, you may not want to claim exempt if you (and/or your spouse when filing
a joint return) expect to have other forms of
income subject to Minnesota tax.
If you claim exempt from Minnesota withholding, you must provide your employer
with a new Form W-4MN by February 15th
of each year.
If another person can claim you as a dependent on his or her federal tax return, you
cannot claim exempt from Minnesota withholding if your annual income exceeds $950
and includes more than $300 of unearned
income.
Use of Information
All information on Form W-4MN is
private by state law. It cannot be given
to others without your consent, except
to the Internal Revenue Service and to
other states that guarantee the same
privacy. Your name, address and Social
Security number are required for
identification. Information about your
allowances is required to determine
your correct tax. We ask for your phone
number so we can call you if we have a
question.
• You are a member of an American Indian
tribe living and working on the reservation of which you are an enrolled member.
OR
• Your wages are for Minnesota National
Guard (MNG) pay or for active duty U.S.
military pay. MNG and active duty U.S.
military members can claim exempt from
Minnesota withholding on these wages,
even if taxable federally. For additional
information, see Income Tax Fact Sheet 5,
Military Personnel.
Employer instructions are on the next page.
Form W-4MN Instructions
Employer Instructions
All new employees must complete federal
Form W-4 when they first begin work for
you. Some employees must also complete
Form W-4MN.
Should my employee complete
Form W-4MN?
Do not have your employee complete Form
W-4MN if they:
• claim the same number of Minnesota
withholding allowances as federal,
• are not requesting additional Minnesota
taxes be withheld from their wages,
AND
• are not claiming to be exempt from Minnesota withholding.
Employees who complete Form MWR
should not complete Form W-4MN. When
determining Minnesota withholding for
employees who do not need to complete
Form W-4MN, use the same number of allowances the employee listed on Form W-4.
You are not required to verify the number of
allowances claimed by each employee.
For more information, see When to Complete under Employee Instructions. Keep all
forms in your records.
Honor each Form W-4MN you receive
unless we notify you otherwise or if the employee claims more Minnesota than federal
allowances. If the employee claims more
Minnesota than federal allowances, use the
number of federal allowances to determine
the Minnesota withholding (see Section 1).
How should I determine Minnesota
withholding for an employee that
doesn’t complete Forms W-4 or
W-4MN?
Withhold Minnesota tax as if the employee
is single with zero withholding allowances.
If your employee claims exempt from Minnesota withholding, they must provide you
with a new Form W-4MN by Feb. 15 of each
year. Exempt forms received during the year
must be submitted to the department within
30 days of receipt from the employee.
Do I need to send a copy of Form
W-4MN to the department?
Send copies of Form W-4MN to the department if the employee:
• claims more than 10 Minnesota withholding allowances; or
• claims to be exempt from Minnesota
withholding and you reasonably expect
the employee’s wages to exceed $200
per week (Exception: If the employee is
a resident of a reciprocity state and has
completed Form MWR); or
• you believe the employee is not entitled to
the number of allowances claimed.
You do not need to submit the Form W4MN to the department if the employee
is asking to have additional Minnesota
withholding deducted from their pay or is
claiming fewer Minnesota withholding allowances than federal.
A $50 penalty may be assessed for each
required Form W-4MN not filed with the
department.
Invalid Forms W-4MN
The following situations make the Form
W-4MN invalid:
• any unauthorized change or addition to
the form, including any change to the language certifying the form is correct;
• if, by the date an employee gives it to
you, he or she indicates in any way the
form is false;
• the form is incomplete or lacks the necessary signatures;
• both Section 1 AND Section 2 were completed;
• the employer information is incomplete.
What do I do if I receive an invalid
Form W-4MN?
Do not use it to figure Minnesota income
tax withholding. Tell the employee it is invalid and they must complete and submit a
new one. If the employee does not give you
a valid one, withhold taxes as if the employee was single and claiming zero withholding
allowances. However, if you have an earlier
Form W-4MN for this worker that is valid,
withhold as you did before.
Questions?
Go to www.revenue.state.mn.us for additional forms and information, fact sheets,
and answers to frequently asked questions.
Email: [email protected]
Phone: 651-282-9999 or 1-800-657-3594.
Information in other formats is available
upon request to persons with disabilities.
Print Form
Reset Form
Form
MO W-4
Missouri Department of Revenue
Employee’s Withholding Allowance Certificate
This certificate is for income tax withholding and child support enforcement purposes only. Type or print.
Full Name
Social Security Number
Filing Status
Home Address (Number and Street or Rural Route)
City or Town
State
Employer
Signature
Employee
Single
r
Married
r
Head of Household
r
Zip Code
1. Allowance For Yourself: Enter 1 for yourself if your filing status is single, married, or head of household..........................1
2. Allowance For Your Spouse: Does your spouse work? r Yes r No If yes, enter 0. If no, enter 1 for your spouse.....2
3. Allowance For Dependents: Enter the number of dependents you will claim on your tax return. Do not claim yourself
or your spouse or dependents that your spouse has already claimed on his or her Form MO W-4.....................................3
4. Additional Allowances: You may claim additional allowances if you itemize your deductions or have other state tax
deductions or credits that lower your tax. Enter the number of additional allowances you would like to claim...................4
5. Total Number Of Allowances You Are Claiming: Add Lines 1 through 4 and enter total here.............................................5
6. Additional Withholding: If you expect to have a balance due (as a result of interest income, dividends, income from a
part-time job, etc.) on your tax return, you may request your employer to withhold an additional amount of tax from
each pay period. To calculate the amount needed, divide the amount of the expected balance due by the number of
pay periods in a year. Enter the additional amount to be withheld each pay period here....................................................6 $
7. Exempt Status: If you had a right to a refund of all of your Missouri income tax withheld last year because you had no
tax liability and this year you expect a refund of all Missouri income tax withheld because you expect to have no tax
liability, write “Exempt” on Line 7. See information below.............................................................................................. 7
8. If you meet the conditions set forth under the Servicemember Civil Relief Act, as amended by the Military Spouses
Residency Relief Act and have no Missouri tax liability, write “Exempt” on line 8. See information below. ................. 8
Under penalties of perjury, I certify that I am entitled to the number of withholding allowances claimed on this certificate, or I am entitled to claim exempt status.
Employee’s Signature (Form is not valid unless you sign it)
Date (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
Employer’s Name
Employer’s Address
City
State
Date Services for Pay First Performed by Employee (MM/DD/YYYY)
__
Zip Code
Federal Employer I.D. Number
__ / __ __ / __ __ __ __
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|
|
|
|
|
Missouri Tax Identification Number
|
|
|
|
|
|
|
|
|
Notice To Employer: Within 20 days of hiring a new employee, send a copy of Form MO W-4 to the Missouri Department of Revenue, P.O. Box 3340,
Jefferson City, MO 65105-3340 or fax to (573) 526-8079.
Employee Information — You Do Not Pay Missouri Income Tax on all of the Income You Earn!
Visit http://www.dort.mo.gov/tax/calculators/withhold/ to try our online withholding calculator.
Form MO W-4 is completed so you can have as much “take-home pay” as possible without an income tax liability due to the state of Missouri
when you file your return. Deductions and exemptions reduce the amount of your taxable income. If your income is less than the total of your personal
exemption plus your standard deduction, you should mark “Exempt” on Line 7 above. The following amounts of your annual Missouri adjusted gross
income will not be taxed by the state of Missouri when you file your individual income tax return.
Single
Married Filing Combined
Head of Household
$2,100 — personal exemption
$6,300 — standard deduction
$8,400 — Total
$ 4,200 — personal exemption
$12,600 — standard deduction
$16,800 — Combined Total (For both spouses)
$ 3,500 — personal exemption
$ 9,300 — standard deduction
$12,800 — Total
+ $1,200 for each dependent
+ up to $5,000 for federal tax
+ $1,200 for each dependent
+ up to $10,000 for federal tax
+ $1,200 for each dependent
+ up to $5,000 for federal tax
Items to Remember:
• If your filing status is married filing combined and your spouse works, do
not claim an exemption on Form MO W-4 for your spouse.
• If you and your spouse have dependents, please be sure only one
of you claim the dependents on your Form MO W-4. If both spouses
claim the dependents as an allowance on Form MO W-4, it may cause
you to owe additional Missouri income tax when you file your return.
• If you have more than one employer, you should claim a smaller number
or no allowances on each Form MO W-4 filed with employers other than
your principal employer so the amount withheld will be closer to your
amount of total tax.
• If you itemize your deductions, instead of using the standard deduction,
the amount not taxed by Missouri may be a greater or lesser amount.
• If you are claiming an “Exempt” status due to the Military Spouses
Residency Relief Act you must provide one of the following to your
employer: Leave and Earnings Statement of the non-resident military
servicemember, Form W-2 issued to the nonresident military
servicemember, a military identification card, or specific military orders
received by the servicemember. You must also provide verification of
residency such as a copy of your state income tax return filed in your
state of residence, a property tax receipt from the state of residence, a
current drivers license, vehicle registration or voter ID card.
Form MO W-4 (Revised 12-2015)
Mail to: Taxation Division
P.O. Box 3340
Jefferson City, MO 65105-3340
Phone: (573) 751-8750
Fax: (573) 526-8079
Visit
http://dss.mo.gov/child-support/employers/new-hire-reporting.htm
for additional information regarding new hire reporting.
Form 89-350-13-8-1-000 (Rev. 12/13)
MISSISSIPPI EMPLOYEE'S WITHHOLDING EXEMPTION CERTIFICATE
Employee's Name
Mississippi Department of Revenue
P.O. Box 960
Jackson, MS 39205
EMPLOYEE:
File this form with your
employer. Otherwise, you
must withhold Mississippi
income tax from the full
amount of your wages.
SSN
Employee's Residence
Address
Number and Street
CLAIM YOUR WITHHOLDING PERSONAL EXEMPTION
Personal Exemption Allowed
Marital Status
1. Single
2. Marital Status
(Check One)
EMPLOYER:
4. Dependents
Number Claimed
5. Age and
Blindness
$
Enter $6,000 as exemption . . . . 
(a)
Spouse NOT employed: Enter $12,000
(b)
Spouse IS employed: Enter that part of
$12,000 claimed by you in multiples of
$500. See instructions 2(b) below .

Enter $9,500 as exemption. To qualify
as head of family, you must be single
and have a dependent living in the
home with you. See instructions 2(c)
and 2(d)below . . . . . . . . . . . .
3. Head of Family
Keep this certificate with
your records. If the
employee is believed to
have claimed excess
exemption, the Department
of Revenue should be
advised.
State
City or Town
Zip Code
Amount Claimed
$
$
$
You may claim $1,500 for each dependent*, other than
for taxpayer and spouse, who receives chief support
from you and who qualifies as a dependent for Federal
income tax purposes.
* A head of family may claim $1,500 for each
dependents excluding the one which qualifies you
as head of family. Multiply number of dependents
claimed by you by $1,500. Enter amount claimed . . . 
● Age 65 or older
Husband
Wife
Single
● Blind
Husband
Wife
Single
Multiply the number of blocks checked by $1,500.
Enter the amount claimed . . . . .
* Note: No exemption allowed for age or blindness
$
$
for dependents.
Military Spouses
Residency Relief Act
Exemption from Mississippi
Withholding
6. TOTAL AMOUNT OF EXEMPTION CLAIMED - Lines 1 through 5...
$
7. Additional dollar amount of withholding per pay period if
agreed to by your employer . . . . . . . . . . . . . . . . .
$
8. If you meet the conditions set forth under the Service Member
Civil Relief, as amended by the Military Spouses Residency
Relief Act, and have no Mississippi tax liability, write
"Exempt" on Line 8. You must attach a copy of the Federal
Form DD-2058 and a copy of your Military Spouse ID Card to
this form so your employer can validate the exemption claim..
I declare under the penalties imposed for filing false reports that the amount of exemption claimed on this
certificate does not exceed the amount to which I am entitled or I am entitled to claim exempt status.
Employee's Signature:
Date:
INSTRUCTIONS
1. The personal exemptions allowed:
(a) Single Individuals
(b) Married Individuals (Jointly)
(c) Head of family
$6,000
$12,000
$9,500
(d) Dependents
(e) Age 65 and Over
(f) Blindness
$1,500
$1,500
$1,500
2. Claiming personal exemptions:
(a) Single Individuals enter $6,000 on Line 1.
(b) Married individuals are allowed a joint exemption of $12,000.
If the spouse is not employed, enter $12,000 on Line 2(a). If the spouse is employed, the
exemption of $12,000 may be divided between taxpayer and spouse in any manner they
choose - in multiples of $500. For example, the taxpayer may claim $6,500 and the spouse
claims $5,500; or the taxpayer may claim $8,000 and the spouse claims $4,000. The total
claimed by the taxpayer and spouse may not exceed $12,000. Enter amount claimed by
you on Line 2(b).
(c) Head of Family
A head of family is a single individual who maintains a home which is the principal place of
abode for himself and at least one other dependent. Single individuals qualifying as a head
of family enter $9,500 on Line 3. If the taxpayer has more than one dependent, additional
exemptions are applicable. See item (d).
(d) An additional exemption of $1,500 may generally be claimed for each dependent of the
taxpayer. A dependent is any relative who receives chief support from the taxpayer and
p
p
y individuals
who q
qualifies as a dependent
for Federal income tax p
purposes.
Head of family
may claim an additional exemption for each dependent excluding the one which is required
for head of family status. For example, a head of family taxpayer has 2 dependent children
and his dependent mother living with him. The taxpayer may claim 2 additional exemptions.
Married or single individuals may claim an additional exemption for each dependent, but
should not include themselves or their spouse. Married taxpayers may divide the number of their
dependents between them in any manner they choose; for example, a married couple has 3 children
who qualify as dependents. The taxpayer may claim 2 dependents and the spouse 1; or the taxpayer
may claim 3 dependents and the spouse none. Enter the amount of dependent exemption on Line 4.
(e) An additional exemption of $1,500 may be claimed by either taxpayer or spouse or both if
either or both have reached the age of 65 before the close of the taxable year. No
additional exemption is authorized for dependents by reason of age. Check applicable
blocks on Line 5.
(f) An additional exemption of $1,500 may be claimed by either taxpayer or spouse or both if
either or both are blind. No additional exemption is authorized for dependents by reason of
blindness. Check applicable blocks on Line 5. Multiply number of blocks checked on Line 5
by $1,500 and enter amount of exemption claimed.
3. Total Exemption Claimed:
Add the amount of exemptions claimed in each category and enter the total on Line 6. This
amount will be used as a basis for withholding income tax under the appropriate withholding
tables.
4. A NEW EXEMPTION CERTIFICATE MUST BE FILED WITH YOUR EMPLOYER WITHIN
30 DAYS AFTER ANY CHANGE IN YOUR EXEMPTION STATUS.
5. PENALTIES ARE IMPOSED FOR WILLFULLY SUPPLYING FALSE INFORMATION
6. IF THE EMPLOYEE FAILS TO FILE AN EXEMPTION CERTIFICATE WITH HIS
EMPLOYER, INCOME TAX MUST BE WITHHELD BY THE EMPLOYER ON TOTAL
WAGES WITHOUT THE BENEFIT OF EXEMPTION..
7. To comply with the Military Spouse Residency Relief Act (PL111-97) signed on November
11, 2009.
Form NJ-W4
State of New Jersey - Division of Taxation
(1-10, R-13)
Employee’s Withholding Allowance Certificate
1. SS#
2. Filing Status: (Check only one box)
1. Single
2. Married/Civil Union Couple Joint
3. Married/Civil Union Partner Separate
4. Head of Household
Name
Address
City
State
Zip
5. Qualifying Widow(er)/Surviving Civil Union Partner
3. If you have chosen to use the chart from instruction A, enter the appropriate letter here . . . . . . . . . . . 3.
4. Total number of allowances you are claiming (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.
5. Additional amount you want deducted from each pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.
$
6. I claim exemption from withholding of NJ Gross Income Tax and I certify that I have met the
conditions in the instructions of the NJ-W4. If you have met the conditions, enter “EXEMPT” here . . . 6.
7. Under penalties of perjury, I certify that I am entitled to the number of withholding allowances claimed on this certificate or entitled to
claim exempt status.
Employee’s Signature
Date
Employer’s Name and Address
Employer Identification Number
BASIC INSTRUCTIONS
Line 1 Enter your name, address and social security number in the spaces provided.
Line 2 Check the box that indicates your filing status. If you checked Box 1 (Single) or Box 3 (Married/Civil Union Partner Separate) you will be withheld at
Rate A.
Note: If you have checked Box 2 (Married/Civil Union Couple Joint), Box 4 (Head of Household) or Box 5 (Qualifying
Widow(er)/Surviving Civil Union Partner) and either your spouse/civil union partner works or you have more than one job
or more than one source of income and the combined total of all wages is greater than $50,000, see instruction A below.
If you do not complete Line 3, you will be withheld at Rate B.
Line 3 If you have chosen to use the wage chart below, enter the appropriate letter.
Line 4 Enter the number of allowances you are claiming. Entering a number on this line will decrease the amount of withholding and could result in an
underpayment on your return.
Line 5 Enter the amount of additional withholdings you want deducted from each pay.
Line 6 Enter “EXEMPT” to indicate that you are exempt from New Jersey Gross Income Tax Withholdings, if you meet one of the following conditions:
• Your filing status is SINGLE or MARRIED/CIVIL UNION PARTNER SEPARATE and your wages plus your taxable nonwage
income will be $10,000 or less for the current year.
• Your filing status is MARRIED/CIVIL UNION COUPLE JOINT, and your wages combined with your spouse’s/civil union
partner’s wages plus your taxable non wage income will be $20,000 or less for the current year.
• Your filing status is HEAD OF HOUSEHOLD or QUALIFYING WIDOW(ER)/SURVIVING CIVIL UNION PARTNER and your
wages plus your taxable nonwage income will be $20,000 or less for the current year.
Your exemption is good for ONE year only. You must complete and submit a form each year certifying you have no New Jersey Gross Income Tax liability and
claim exemption from withholding. If you have questions about eligibility, filing status, withholding rates, etc. when completing this form, call the Division of
Taxation’s Customer Service Center at 609-292-6400.
Instruction A - Wage Chart
This chart is designed to increase withholdings on your wages, if these wages will be taxed at a higher rate due to inclusion of other wages or income on
your NJ-1040 return. It is not intended to provide withholding for other income or wages. If you need additional withholdings for other income or wages
use Line 5 on the NJ-W4. This Wage Chart applies to taxpayers who are married/civil union couple filing jointly, heads of households or qualifying
widow(er)/surviving civil union partner. Single individuals or married/civil union partners filing separate returns do not need to use this chart. If you
have indicated filing status #2, 4 or 5 on the above NJ-W4 and your taxable income is greater than $50,000, you should strongly consider using the Wage
Chart. (See the Rate Tables on the reverse side to estimate your withholding amount).
WAGE CHART
HOW TO USE THE CHART
Total of All
Other Wages
0
10,000
10,001
20,000
20,001
30,000
30,001
40,000
40,001
50,000
50,001
60,000
60,001
70,000
70,001
80,000
80,001
90,000
OVER
90,000
1) Find the amount of your wages in the left-hand column.
0
10,000
B
B
B
B
B
B
B
B
B
B
2) Find the amount of the total for all other wages (including
your spouse’s/civil union partner’s wages) along the top
row.
10,001
20,000
B
B
B
B
C
C
C
C
C
C
20,001
30,000
B
B
B
A
A
D
D
D
D
D
30,001
40,000
B
B
A
A
A
A
A
E
E
E
40,001
50,000
B
C
A
A
A
A
A
E
E
E
50,001
60,000
B
C
D
A
A
A
E
E
E
E
60,001
70,000
B
C
D
A
A
E
E
E
E
E
70,001
80,000
B
C
D
E
E
E
E
E
E
E
80,001
90,000
B
C
D
E
E
E
E
E
E
E
over
90,000
B
C
D
E
E
E
E
E
E
E
3) Follow along the row that contains your wages until you
come to the column that contains the other wages.
4) This meeting point indicates the Withholding Table that best
reflects your income situation.
5) If you have chosen this method, enter the “letter” of the
withholding rate table on Line 3 of the NJ-W4.
NOTE: If your income situation substantially increases (or
decreases) in the future, you should resubmit a
revised NJ-W4 to your employer.
THIS FORM MAY BE REPRODUCED
Y
O
U
R
W
A
G
E
S
RATE TABLES FOR WAGE CHART
The rate tables listed below correspond to the letters in the Wage Chart on the front page. Use these to estimate the amount
of withholding that will occur if you choose to use the wage chart. Compare this to your estimated income tax liability for your
New Jersey Income Tax return to see if this is the correct amount of withholding that you should have.
RATE ‘A’
WEEKLY PAYROLL PERIOD (Allowance $19.20)
If the amount of taxable
The amount of income
wages is:
tax to be withheld is:
Over
$
$
$
$
$
$
0
384
673
769
1,442
9,615
But Not Over
$
384
$
673
$
769
$
1,442
$
$
$
$
$
5.76
11.54
15.28
56.34
628.45
+
+
+
+
+
1.5%
2.0%
3.9%
6.1%
7.0%
9.9%
Of Excess Over
$
0
$
384
$
673
$
769
$
1,442
$
9,615
ANNUAL PAYROLL PERIOD (Allowance $1,000)
If the amount of taxable
The amount of income
wages is:
tax to be withheld is:
Over
$
0
$ 20,000
$ 35,000
$ 40,000
$ 75,000
$ 500,000
But Not Over
$
20,000
$
35,000
$
40,000
$
75,000
$
300.00 +
$
600.00 +
$
795.00 +
$ 2,930.00 +
$ 32,680.00 +
1.5%
2.0%
3.9%
6.1%
7.0%
9.9%
Of Excess Over
$
0
$
20,000
$
35,000
$
40,000
$
75,000
$
500,000
RATE ‘B’
WEEKLY PAYROLL PERIOD (Allowance $19.20)
If the amount of taxable
The amount of income
wages is:
tax to be withheld is:
Over
$
$
$
$
$
$
$
0
384
961
1,346
1,538
2,884
9,615
But Not Over
$
384
$
961
$
1,346
$
1,538
2,884
$
$
$
$
$
$
5.76
17.30
27.70
35.18
117.29
588.46
+
+
+
+
+
+
1.5%
2.0%
2.7%
3.9%
6.1%
7.0%
9.9%
ANNUAL PAYROLL PERIOD (Allowance $1,000)
If the amount of taxable
The amount of income
wages is:
tax to be withheld is:
Of Excess Over
$
0
$
384
$
961
$
1,346
$
1,538
$
2,884
$
9,615
Over
$
0
$ 20,000
$ 50,000
$ 70,000
$ 80,000
$ 150,000
$ 500,000
But Not Over
$
20,000
$
50,000
$
70,000
$
80,000
$
150,000
$ 300.00
$ 900.00
$ 1,440.00
$ 1,830.00
$ 6,100.00
$ 30,600.00
+
+
+
+
+
+
1.5%
2.0%
2.7%
3.9%
6.1%
7.0%
9.9%
Of Excess Over
$
0
$
20,000
$
50,000
$
70,000
$
80,000
$
150,000
$
500,000
RATE ‘C’
WEEKLY PAYROLL PERIOD (Allowance $19.20)
If the amount of taxable
The amount of income
wages is:
tax to be withheld is:
Over
$
$
$
$
$
$
$
0
384
769
961
1,153
2,884
9,615
But Not Over
$
384
$
769
$
961
$
1,153
$
2,884
$
$
$
$
$
$
5.76
14.62
19.99
26.71
123.65
567.90
+
+
+
+
+
+
1.5%
2.3%
2.8%
3.5%
5.6%
6.6%
9.9%
ANNUAL PAYROLL PERIOD (Allowance $1,000)
If the amount of taxable
The amount of income
wages is:
tax to be withheld is:
Of Excess Over
$
0
$
384
$
769
$
961
$
1,153
$
2,884
$
9,615
Over
$
0
$ 20,000
$ 40,000
$ 50,000
$ 60,000
$ 150,000
$ 500,000
But Not Over
$
20,000
$
40,000
$
50,000
$
60,000
$
150,000
$
300.00
$
760.00
$ 1,040.00
$ 1,390.00
$ 6,430.00
$ 29,530.00
+
+
+
+
+
+
1.5%
2.3%
2.8%
3.5%
5.6%
6.6%
9.9%
Of Excess Over
$
0
$
20,000
$
40,000
$
50,000
$
60,000
$
150,000
$
500,000
RATE ‘D’
WEEKLY PAYROLL PERIOD (Allowance $19.20)
If the amount of taxable
The amount of income
wages is:
tax to be withheld is:
Over
$
$
$
$
$
$
$
0
384
769
961
1,153
2,884
9,615
But Not Over
$
384
$
769
$
961
$
1,153
$
2,884
$
$
$
$
$
$
5.76
16.16
22.68
30.94
127.88
565.40
+
+
+
+
+
+
1.5%
2.7%
3.4%
4.3%
5.6%
6.5%
9.9%
ANNUAL PAYROLL PERIOD (Allowance $1,000)
If the amount of taxable
The amount of income
wages is:
tax to be withheld is:
Of Excess Over
$
0
$
384
$
769
$
961
$
1,153
$
2,884
$
9,615
Over
$
0
$ 20,000
$ 40,000
$ 50,000
$ 60,000
$ 150,000
$ 500,000
But Not Over
$
20,000
$
40,000
$
50,000
$
60,000
$
150,000
$
$
$
$
$
$
300.00
840.00
1,180.00
1,610.00
6,650.00
29,400.00
+
+
+
+
+
+
1.5%
2.7%
3.4%
4.3%
5.6%
6.5%
9.9%
Of Excess Over
$
0
$
20,000
$
40,000
$
50,000
$
60,000
$
150,000
$
500,000
RATE ‘E’
WEEKLY PAYROLL PERIOD (Allowance $19.20)
If the amount of taxable
The amount of income
wages is:
tax to be withheld is:
Over
$
$
$
$
$
0
384
673
1,923
9,615
But Not Over
$
384
$
673
$
1,923
$
$
$
$
5.76
11.54
84.04
584.20
+
+
+
+
1.5%
2.0%
5.8%
6.5%
9.9%
Of Excess Over
$
0
$
384
$
673
$
1,923
$
9,615
ANNUAL PAYROLL PERIOD (Allowance $1,000)
If the amount of taxable
The amount of income
wages is:
tax to be withheld is:
Over
$
0
$ 20,000
$ 35,000
$ 100,000
$ 500,000
But Not Over
$
20,000
$
35,000
$
100,000
$
300.00 +
$
600.00 +
$ 4,370.00 +
$ 30,370.00 +
1.5%
2.0%
5.8%
6.5%
9.9%
Of Excess Over
$
0
$
20,000
$
35,000
$
100,000
$
500,000
Department of Taxation and Finance
Employee’s Withholding Allowance Certificate
IT-2104
New York State • New York City • Yonkers
First name and middle initial
Last name
Permanent home address (number and street or rural route)
City, village, or post office
Apartment number
State
ZIP code
Your social security number
Single or Head of household
Married
Married, but withhold at higher single rate
Note: If married but legally separated, mark an X in
the Single or Head of household box.
Are you a resident of New York City? ............Yes
No
Are you a resident of Yonkers?......................Yes
No
Complete the worksheet on page 3 before making any entries.
1 Total number of allowances you are claiming for New York State and Yonkers, if applicable (from line 17) ............ 1
2 Total number of allowances for New York City (from line 28) ................................................................................... 2
Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.
3 New York State amount ......................................................................................................................................... 3
4 New York City amount ........................................................................................................................................... 4
5 Yonkers amount ..................................................................................................................................................... 5
I certify that I am entitled to the number of withholding allowances claimed on this certificate.
Employee’s signature
Date
Penalty – A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld
from your wages. You may also be subject to criminal penalties.
Employee: detach this page and give it to your employer; keep a copy for your records.
Employer: Keep this certificate with your records.
Mark an X in box A and/or box B to indicate why you are sending a copy of this form to New York State (see instructions):
A Employee claimed more than 14 exemption allowances for NYS .............A
B Employee is a new hire or a rehire.... B
First date employee performed services for pay (mm-dd-yyyy) (see instr.):
Are dependent health insurance benefits available for this employee? .............. YesNo
If Yes, enter the date the employee qualifies (mm-dd-yyyy):
Employer’s name and address (Employer: complete this section only if you are sending a copy of this form to the NYS Tax Department.) Employer identification number
Instructions
Changes effective for 2016
Form IT-2104 has been revised for tax year 2016. The worksheet on
page 3 and the charts beginning on page 4, used to compute withholding
allowances or to enter an additional dollar amount on line(s) 3, 4, or 5,
have been revised. If you previously filed a Form IT-2104 and used the
worksheet or charts, you should complete a new 2016 Form IT-2104 and
give it to your employer.
Who should file this form
This certificate, Form IT-2104, is completed by an employee and given
to the employer to instruct the employer how much New York State (and
New York City and Yonkers) tax to withhold from the employee’s pay. The
more allowances claimed, the lower the amount of tax withheld.
If you do not file Form IT-2104, your employer may use the same number
of allowances you claimed on federal Form W‑4. Due to differences in
tax law, this may result in the wrong amount of tax withheld for New York
State, New York City, and Yonkers. Complete Form IT-2104 each year
and file it with your employer if the number of allowances you may claim
is different from federal Form W-4 or has changed. Common reasons for
completing a new Form IT-2104 each year include the following:
• You started a new job.
• You are no longer a dependent.
• Your individual circumstances may have changed (for example, you
were married or have an additional child).
• You moved into or out of NYC or Yonkers.
• You itemize your deductions on your personal income tax return.
• You claim allowances for New York State credits.
• You owed tax or received a large refund when you filed your personal
income tax return for the past year.
• Your wages have increased and you expect to earn $106,950 or more
during the tax year.
• The total income of you and your spouse has increased to $106,950 or
more for the tax year.
• You have significantly more or less income from other sources or from
another job.
• You no longer qualify for exemption from withholding.
Page 2 of 7IT-2104 (2016)
• You have been advised by the Internal Revenue Service that you
are entitled to fewer allowances than claimed on your original federal
Form W-4, and the disallowed allowances were claimed on your
original Form IT‑2104.
Exemption from withholding
You cannot use Form IT-2104 to claim exemption from withholding.
To claim exemption from income tax withholding, you must file
Form IT-2104-E, Certificate of Exemption from Withholding, with your
employer. You must file a new certificate each year that you qualify for
exemption. This exemption from withholding is allowable only if you had
no New York income tax liability in the prior year, you expect none in the
current year, and you are over 65 years of age, under 18, or a full-time
student under 25. You may also claim exemption from withholding if
you are a military spouse and meet the conditions set forth under the
Servicemembers Civil Relief Act as amended by the Military Spouses
Residency Relief Act. If you are a dependent who is under 18 or a
full-time student, you may owe tax if your income is more than $3,100.
Withholding allowances
You may not claim a withholding allowance for yourself or, if married,
your spouse. Claim the number of withholding allowances you compute
in Part 1 and Part 3 on page 3 of this form. If you want more tax
withheld, you may claim fewer allowances. If you claim more than
14 allowances, your employer must send a copy of your Form IT-2104
to the New York State Tax Department. You may then be asked to
verify your allowances. If you arrive at negative allowances (less than
zero) on lines 1 or 2 and your employer cannot accommodate negative
allowances, enter 0 and see Additional dollar amount(s) below.
Income from sources other than wages – If you have more than
$1,000 of income from sources other than wages (such as interest,
dividends, or alimony received), reduce the number of allowances
claimed on line 1 and line 2 (if applicable) of the IT-2104 certificate by one
for each $1,000 of nonwage income. If you arrive at negative allowances
(less than zero), see Withholding allowances above. You may also
consider filing estimated tax, especially if you have significant amounts
of nonwage income. Estimated tax requires that payments be made by
the employee directly to the Tax Department on a quarterly basis. For
more information, see the instructions for Form IT‑2105, Estimated Tax
Payment Voucher for Individuals, or see Need help? on page 6.
Other credits (Worksheet line 13) – If you will be eligible to claim
any credits other than the credits listed in the worksheet, such as an
investment tax credit, you may claim additional allowances.
Find your filing status and your New York adjusted gross income (NYAGI)
in the chart below, and divide the amount of the expected credit by the
number indicated. Enter the result (rounded to the nearest whole number)
on line 13.
Single and Head of household Married
Divide amount of
NYAGI is: and NYAGI is:
and NYAGI is: expected credit by:
Less than
$214,000
Between $214,000 and
$1,070,350
Over
$1,070,350
Less than $267,500
Between
$267,500 and
$1,605,650
Over
$1,605,650
Less than
$321,050
Between
$321,050 and
$2,140,900
Over
$2,140,900
66
68
88
Example: You are married and expect your New York adjusted gross
income to be less than $321,050. In addition, you expect to receive a
flow-through of an investment tax credit from the S corporation of which
you are a shareholder. The investment tax credit will be $160. Divide
the expected credit by 66. 160/66 = 2.4242. The additional withholding
allowance(s) would be 2. Enter 2 on line 13.
Married couples with both spouses working – If you and your spouse
both work, you should each file a separate IT‑2104 certificate with your
respective employers. Your withholding will better match your total tax if
the higher wage‑earning spouse claims all of the couple’s allowances and
the lower wage‑earning spouse claims zero allowances. Do not claim
more total allowances than you are entitled to. If your combined wages
are:
• less than $106,950, you should each mark an X in the box Married,
but withhold at higher single rate on the certificate front, and divide the
total number of allowances that you compute on line 17 and line 28 (if
applicable) between you and your working spouse.
• $106,950 or more, use the chart(s) in Part 4 and enter the additional
withholding dollar amount on line 3.
Taxpayers with more than one job – If you have more than one job,
file a separate IT-2104 certificate with each of your employers. Be
sure to claim only the total number of allowances that you are entitled
to. Your withholding will better match your total tax if you claim all of
your allowances at your higher-paying job and zero allowances at
the lower-paying job. In addition, to make sure that you have enough
tax withheld, if you are a single taxpayer or head of household with
two or more jobs, and your combined wages from all jobs are under
$106,950, reduce the number of allowances by seven on line 1 and
line 2 (if applicable) on the certificate you file with your higher‑paying
job employer. If you arrive at negative allowances (less than zero), see
Withholding allowances above.
If you are a single or a head of household taxpayer, and your combined
wages from all of your jobs are between $106,950 and $2,248,076, use
the chart(s) in Part 5 and enter the additional withholding dollar amount
from the chart on line 3.
If you are a married taxpayer, and your combined wages from all of
your jobs are $106,950 or more, use the chart(s) in Part 4 and enter the
additional withholding dollar amount from the chart on line 3 (Substitute
the words Higher-paying job for Higher earner’s wages within the chart).
Dependents – If you are a dependent of another taxpayer and expect
your income to exceed $3,100, you should reduce your withholding
allowances by one for each $1,000 of income over $2,500. This will
ensure that your employer withholds enough tax.
Following the above instructions will help to ensure that you will not owe
additional tax when you file your return.
Heads of households with only one job – If you will use the
head-of-household filing status on your state income tax return, mark
the Single or Head of household box on the front of the certificate. If you
have only one job, you may also wish to claim two additional withholding
allowances on line 14.
Additional dollar amount(s)
You may ask your employer to withhold an additional dollar amount each
pay period by completing lines 3, 4, and 5 on Form IT‑2104. In most
instances, if you compute a negative number of allowances and your
employer cannot accommodate a negative number, for each negative
allowance claimed you should have an additional $1.85 of tax withheld per
week for New York State withholding on line 3, and an additional $0.80
of tax withheld per week for New York City withholding on line 4. Yonkers
residents should use 16.75% (.1675) of the New York State amount for
additional withholding for Yonkers on line 5.
Note: If you are requesting your employer to withhold an additional dollar
amount on lines 3, 4, or 5 of this allowance certificate, the additional
dollar amount, as determined by these instructions or by using the
chart(s) in Part 4 or Part 5, is accurate for a weekly payroll. Therefore,
if you are not paid on a weekly basis, you will need to adjust the dollar
amount(s) that you compute. For example, if you are paid biweekly, you
must double the dollar amount(s) computed.
Avoid underwithholding
Form IT‑2104, together with your employer’s withholding tables, is
designed to ensure that the correct amount of tax is withheld from your pay.
If you fail to have enough tax withheld during the entire year, you may owe
a large tax liability when you file your return. The Tax Department must
assess interest and may impose penalties in certain situations in addition
to the tax liability. Even if you do not file a return, we may determine
that you owe personal income tax, and we may assess interest and
penalties on the amount of tax that you should have paid during the year.
(continued)
IT-2104 (2016) Page 3 of 7
Employers
Box A – If you are required to submit a copy of an employee’s
Form IT-2104 to the Tax Department because the employee claimed
more than 14 allowances, mark an X in box A and send a copy
of Form IT-2104 to: NYS Tax Department, Income Tax Audit
Administrator, Withholding Certificate Coordinator, W A Harriman
Campus, Albany NY 12227-0865. If the employee is also a new hire or
rehire, see Box B instructions. See Publication 55, Designated Private
Delivery Services, if not using U.S. Mail.
Due dates for sending certificates received from employees claiming
more than 14 allowances are:
Quarter
Due date
Quarter
Due date
January – March
April 30
July – September
October 31
April – June
July 31
October – December
January 31
Box B – If you are submitting a copy of this form to comply with New
York State’s New Hire Reporting Program, mark an X in box B. Enter the
first day any services are performed for which the employee will be paid
wages, commissions, tips and any other type of compensation. For
services based solely on commissions, this is the first day an employee
working for commissions is eligible to earn commissions. Also, mark an X
in the Yes or No box indicating if dependent health insurance benefits are
available to this employee. If Yes, enter the date the employee qualifies
for coverage. Mail the completed form, within 20 days of hiring, to: NYS
Tax Department, New Hire Notification, PO Box 15119, Albany NY
12212-5119. To report newly-hired or rehired employees online instead of
submitting this form, go to www.nynewhire.com.
Worksheet
See the instructions before completing this worksheet.
Part 1 – Complete this part to compute your withholding allowances for New York State and Yonkers (line 1).
6 Enter the number of dependents that you will claim on your state return (do not include yourself or, if married, your spouse) ...... 6
For lines 7, 8, and 9, enter 1 for each credit you expect to claim on your state return.
7
College tuition credit ................................................................................................................................................................... 7
8
New York State household credit ................................................................................................................................................ 8
9 Real property tax credit ............................................................................................................................................................... 9
For lines 10, 11, and 12, enter 3 for each credit you expect to claim on your state return.
10 Child and dependent care credit ................................................................................................................................................. 10
11 Earned income credit .................................................................................................................................................................. 11
12 Empire State child credit ............................................................................................................................................................. 12
13 Other credits (see instructions) ....................................................................................................................................................... 13
14 Head of household status and only one job (enter 2 if the situation applies).................................................................................... 14
15 Enter an estimate of your federal adjustments to income, such as alimony you will pay for the tax year
and deductible IRA contributions you will make for the tax year. Total estimate $ .
Divide this estimate by $1,000. Drop any fraction and enter the number ............................................................................... 15
16 If you expect to itemize deductions on your state tax return, complete Part 2 below and enter the number from line 25.
All others enter 0 .................................................................................................................................................................... 16
17 Add lines 6 through 16. Enter the result here and on line 1. If you have more than one job, or if you and your spouse both
work, see instructions for Taxpayers with more than one job or Married couples with both spouses working. ...................... 17
Part 2 – Complete this part only if you expect to itemize deductions on your state return.
18
Enter your estimated federal itemized deductions for the tax year............................................................................................ 18
19 Enter your estimated state, local, and foreign income taxes or state and local general sales taxes included on line 18 ......... 19
20 Subtract line 19 from line 18 ..................................................................................................................................................... 20
21 Enter your estimated college tuition itemized deduction ........................................................................................................... 21
22 Add lines 20 and 21 .................................................................................................................................................................. 22
23 Based on your federal filing status, enter the applicable amount from the table below ............................................................ 23
Standard deduction table
Single (cannot be claimed as a dependent) ..... $ 7,950
Single (can be claimed as a dependent) ........ $ 3,100
Head of household ......................................... $11,150
Qualifying widow(er) ......................................... $15,950
Married filing jointly ........................................... $15,950
Married filing separate returns .......................... $ 7,950
24 Subtract line 23 from line 22 (if line 23 is larger than line 22, enter 0 here and on line 16 above) ........................................................ 24
25 Divide line 24 by $1,000. Drop any fraction and enter the result here and on line 16 above .................................................... 25
Part 3 – Complete this part to compute your withholding allowances for New York City (line 2).
26
Enter the amount from line 6 above .......................................................................................................................................... 26
27 Add lines 14 through 16 above and enter total here ................................................................................................................. 27
28 Add lines 26 and 27. Enter the result here and on line 2 .......................................................................................................... 28
Page 4 of 7 IT-2104 (2016)
Part 4 – These charts are only for married couples with both spouses working or married couples with one spouse working more than
one job, and whose combined wages are between $106,950 and $2,248,076.
Enter the additional withholding dollar amount on line 3.
The additional dollar amount, as shown below, is accurate for a weekly payroll. If you are not paid on a weekly basis, you will need to
adjust these dollar amount(s). For example, if you are paid biweekly, you must double the dollar amount(s) computed.
Combined wages between $106,950 and $535,149
$106,950$128,400$149,750$171,150$192,550$235,400$278,250$321,050$374,600$428,100$481,650
Higher earner’s wages $128,399$149,749$171,149$192,549$235,399$278,249$321,049$374,599$428,099$481,649$535,149
$53,450
$74,799
$12
$16
$74,800
$96,199
$11
$17
$22
$27
$96,200
$117,649
$8
$15
$20
$27
$35
$117,650
$128,399
$2
$10
$16
$23
$32
$31
$128,400
$139,099
$4
$13
$20
$30
$29
$139,100
$149,749
$2
$10
$17
$27
$29
$26
$149,750
$160,499
$4
$15
$25
$29
$24
$160,500
$171,349
$2
$11
$22
$27
$24
$22
$171,350
$192,549
$4
$17
$22
$23
$22
$18
$192,550
$235,399
$6
$12
$18
$20
$19
$19
$235,400
$278,249
$6
$12
$23
$25
$19
$18
$278,250
$321,049
$6
$18
$30
$26
$19
$321,050
$374,599
$10
$20
$27
$22
$374,600
$428,099
$8
$16
$23
$428,100
$481,649
$8
$16
$481,650
$535,149
$8
Combined wages between $535,150 and $1,177,449
$535,150$588,700$642,200$695,700$749,250$802,800$856,300$909,850$963,400$1,016,900
$1,070,350
$1,123,950
Higher earner’s wages $588,699$642,199$695,699$749,249$802,799$856,299$909,849$963,399$1,016,899
$1,070,349
$1,123,949
$1,177,449
$235,400
$278,249
$18
$278,250
$321,049
$20
$16
$321,050
$374,599
$15
$17
$19
$14
$374,600
$428,099
$18
$11
$13
$15
$7
$7
$428,100
$481,649
$23
$18
$11
$13
$15
$7
$7
$7
$481,650
$535,149
$16
$23
$18
$11
$13
$15
$7
$7
$7
$7
$535,150
$588,699
$8
$16
$23
$18
$11
$13
$15
$7
$7
$7
$8
$11
$588,700
$642,199
$8
$16
$23
$18
$11
$13
$15
$7
$7
$8
$11
$642,200
$695,699
$8
$16
$23
$18
$11
$13
$15
$7
$8
$11
$695,700
$749,249
$8
$16
$23
$18
$11
$13
$15
$8
$11
$749,250
$802,799
$8
$16
$23
$18
$11
$13
$16
$11
$802,800
$856,299
$8
$16
$23
$18
$11
$14
$19
$856,300
$909,849
$8
$16
$23
$18
$12
$17
$909,850
$963,399
$8
$16
$23
$20
$15
$963,400
$1,016,899
$8
$16
$24
$23
$1,016,900
$1,070,349
$8
$17
$27
$1,070,350
$1,123,949
$9
$19
$1,123,950
$1,177,449
$9
IT-2104 (2016) Page 5 of 7
Combined wages between $1,177,450 and $1,712,749
$1,177,450$1,230,950$1,284,550$1,338,050$1,391,550$1,445,100$1,498,600$1,552,100$1,605,650$1,659,200
Higher earner’s wages $1,230,949$1,284,549$1,338,049$1,391,549$1,445,099$1,498,599$1,552,099$1,605,649$1,659,199$1,712,749
$588,700
$642,199
$14
$17
$642,200
$695,699
$14
$17
$21
$24
$695,700
$749,249
$14
$17
$21
$24
$27
$30
$749,250
$802,799
$14
$17
$21
$24
$27
$30
$33
$36
$802,800
$856,299
$14
$17
$21
$24
$27
$30
$33
$36
$39
$42
$856,300
$909,849
$23
$17
$21
$24
$27
$30
$33
$36
$39
$42
$909,850
$963,399
$21
$26
$21
$24
$27
$30
$33
$36
$39
$42
$963,400
$1,016,899
$18
$24
$29
$24
$27
$30
$33
$36
$39
$42
$1,016,900
$1,070,349
$26
$22
$27
$32
$27
$30
$33
$36
$39
$42
$1,070,350
$1,123,949
$29
$27
$23
$28
$33
$28
$31
$34
$37
$41
$1,123,950
$1,177,449
$19
$29
$27
$23
$28
$33
$28
$31
$34
$37
$1,177,450
$1,230,949
$9
$19
$29
$27
$23
$28
$33
$28
$31
$34
$1,230,950
$1,284,549
$9
$19
$29
$27
$23
$28
$33
$28
$31
$1,284,550
$1,338,049
$9
$19
$29
$27
$23
$28
$33
$28
$1,338,050
$1,391,549
$9
$19
$29
$27
$23
$28
$33
$1,391,550
$1,445,099
$9
$19
$29
$27
$23
$28
$1,445,100
$1,498,599
$9
$19
$29
$27
$23
$1,498,600
$1,552,099
$9
$19
$29
$28
$1,552,100
$1,605,649
$9
$19
$29
$1,605,650
$1,659,199
$9
$19
$1,659,200
$1,712,749
$9
Combined wages between $1,712,750 and $2,248,076
$1,712,750$1,766,250$1,819,800$1,873,300$1,926,800$1,980,350$2,033,900$2,087,400$2,140,900$2,194,500
Higher earner’s wages $1,766,249$1,819,799$1,873,299$1,926,799$1,980,349$2,033,899$2,087,399$2,140,899$2,194,499$2,248,076
$856,300
$909,849
$45
$48
$909,850
$963,399
$45
$48
$51
$54
$963,400
$1,016,899
$45
$48
$51
$54
$58
$61
$1,016,900
$1,070,349
$45
$48
$51
$54
$58
$61
$64
$67
$1,070,350
$1,123,949
$44
$47
$50
$53
$56
$59
$62
$65
$484
$1,123,950
$1,177,449
$41
$44
$47
$50
$53
$56
$59
$62
$481
$911
$1,177,450
$1,230,949
$37
$41
$44
$47
$50
$53
$56
$59
$478
$908
$1,230,950
$1,284,549
$34
$37
$41
$44
$47
$50
$53
$56
$475
$905
$1,284,550
$1,338,049
$31
$34
$37
$41
$44
$47
$50
$53
$472
$902
$1,338,050
$1,391,549
$28
$31
$34
$38
$41
$44
$47
$50
$468
$899
$1,391,550
$1,445,099
$33
$28
$31
$34
$37
$41
$44
$47
$465
$896
$1,445,100
$1,498,599
$28
$33
$28
$31
$34
$37
$41
$44
$462
$893
$1,498,600
$1,552,099
$23
$28
$33
$28
$31
$34
$37
$41
$459
$889
$1,552,100
$1,605,649
$27
$23
$28
$33
$28
$31
$34
$37
$456
$886
$1,605,650
$1,659,199
$29
$27
$23
$28
$33
$28
$31
$34
$453
$883
$1,659,200
$1,712,749
$19
$29
$27
$23
$28
$33
$28
$31
$450
$880
$1,712,750
$1,766,249
$9
$19
$29
$27
$23
$28
$33
$28
$447
$877
$1,766,250
$1,819,799
$9
$19
$29
$27
$23
$28
$33
$444
$874
$1,819,800
$1,873,299
$9
$19
$29
$27
$23
$28
$449
$871
$1,873,300
$1,926,799
$9
$19
$29
$27
$23
$444
$876
$1,926,800
$1,980,349
$9
$19
$29
$27
$439
$871
$1,980,350
$2,033,899
$9
$19
$29
$443
$866
$2,033,900
$2,087,399
$9
$19
$444
$870
$2,087,400
$2,140,899
$9
$434
$871
$2,140,900
$2,194,499
$218
$446
$2,194,500
$2,248,076
$14
$911
Note: These charts do not account for additional withholding in the following instances:
• a married couple with both spouses working, where one spouse’s wages are more than $1,124,038 but less than $2,248,076, and the other spouse’s wages are also more than $1,124,038 but less than $2,248,076;
• married taxpayers with only one spouse working, and that spouse works more than one job, with wages from each job under $2,248,076, but combined wages from all jobs is over $2,248,076.
If you are in one of these situations and you would like to request an additional dollar amount of withholding from your wages, please contact the Tax
Department for assistance (see Need help? on page 6).
Page 6 of 7 IT-2104 (2016)
Part 5 – These charts are only for single taxpayers and head of household taxpayers with more than one job, and whose combined
wages are between $106,950 and $2,248,076. Enter the additional withholding dollar amount on line 3.
The additional dollar amount, as shown below, is accurate for a weekly payroll. If you are not paid on a weekly basis, you will need to
adjust these dollar amount(s). For example, if you are paid biweekly, you must double the dollar amount(s) computed.
Combined wages between $106,950 and $535,149
Higher wage
$106,950$128,400$149,750$171,150$192,550$235,400$278,250$321,050$374,600$428,100$481,650
$128,399$149,749$171,149$192,549$235,399$278,249$321,049$374,599$428,099$481,649$535,149
$53,450
$74,799
$13
$18
$74,800
$96,199
$13
$19
$26
$25
$96,200
$117,649
$8
$17
$23
$26
$27
$117,650
$128,399
$2
$11
$18
$21
$25
$28
$128,400
$139,099
$4
$15
$18
$22
$28
$139,100
$149,749
$2
$11
$14
$19
$28
$26
$149,750
$160,499
$4
$11
$15
$28
$24
$160,500
$171,349
$2
$8
$13
$27
$25
$21
$171,350
$192,549
$3
$11
$25
$28
$22
$24
$192,550
$235,399
$8
$20
$29
$26
$24
$18
$235,400
$278,249
$8
$16
$23
$18
$18
$12
$278,250
$321,049
$7
$15
$22
$15
$16
$321,050
$374,599
$8
$16
$22
$15
$374,600
$428,099
$8
$16
$22
$428,100
$481,649
$8
$16
$481,650
$535,149
$8
Combined wages between $535,150 and $1,177,449
Higher wage
$535,150$588,700$642,200$695,700$749,250$802,800$856,300$909,850$963,400$1,016,900
$1,070,350
$1,123,950
$588,699$642,199$695,699$749,249$802,799$856,299$909,849$963,399$1,016,899
$1,070,349
$1,123,949
$1,177,449
$235,400
$278,249
$9
$278,250
$321,049
$9
$8
$321,050
$374,599
$17
$8
$8
$8
$374,600
$428,099
$15
$17
$8
$8
$8
$8
$428,100
$481,649
$22
$15
$17
$8
$8
$8
$8
$8
$481,650
$535,149
$16
$22
$15
$17
$8
$8
$8
$8
$8
$8
$535,150
$588,699
$8
$16
$22
$15
$17
$8
$8
$8
$8
$8
$224
$450
$588,700
$642,199
$8
$16
$22
$15
$17
$8
$8
$8
$8
$224
$450
$642,200
$695,699
$8
$16
$22
$15
$17
$8
$8
$8
$224
$450
$695,700
$749,249
$8
$16
$22
$15
$17
$8
$8
$224
$450
$749,250
$802,799
$8
$16
$22
$15
$17
$8
$224
$450
$802,800
$856,299
$8
$16
$22
$15
$17
$224
$450
$856,300
$909,849
$8
$16
$22
$15
$232
$450
$909,850
$963,399
$8
$16
$22
$230
$458
$963,400
$1,016,899
$8
$16
$237
$456
$1,016,900
$1,070,349
$8
$231
$463
$1,070,350
$1,123,949
$115
$242
$1,123,950
$1,177,449
$14
(Part 5 continued on page 7)
Privacy notification
See our Web site or Publication 54, Privacy Notification.
Need help?
Visit our Web site at www.tax.ny.gov
• get information and manage your taxes online
• check for new online services and features
Telephone assistance
Automated income tax refund status: (518) 457-5149
Personal Income Tax Information Center: (518) 457-5181
To order forms and publications:
(518) 457-5431
Text Telephone (TTY) Hotline (for persons with
hearing and speech disabilities using a TTY): (518) 485-5082
IT-2104 (2016) Page 7 of 7
Combined wages between $1,177,450 and $1,712,749
Higher wage
$1,177,450$1,230,950$1,284,550$1,338,050$1,391,550$1,445,100$1,498,600$1,552,100$1,605,650$1,659,200
$1,230,949$1,284,549$1,338,049$1,391,549$1,445,099$1,498,599$1,552,099$1,605,649$1,659,199$1,712,749
$588,700
$642,199
$473
$496
$642,200
$695,699
$473
$496
$520
$543
$695,700
$749,249
$473
$496
$520
$543
$566
$590
$749,250
$802,799
$473
$496
$520
$543
$566
$590
$613
$637
$802,800
$856,299
$473
$496
$520
$543
$566
$590
$613
$637
$660
$683
$856,300
$909,849
$473
$496
$520
$543
$566
$590
$613
$637
$660
$683
$909,850
$963,399
$473
$496
$520
$543
$566
$590
$613
$637
$660
$683
$963,400
$1,016,899
$481
$496
$520
$543
$566
$590
$613
$637
$660
$683
$1,016,900
$1,070,349
$479
$505
$520
$543
$566
$590
$613
$637
$660
$683
$1,070,350
$1,123,949
$271
$287
$313
$328
$351
$375
$398
$421
$445
$468
$1,123,950
$1,177,449
$39
$69
$85
$110
$125
$149
$172
$195
$219
$242
$1,177,450
$1,230,949
$14
$39
$69
$85
$110
$125
$149
$172
$195
$219
$1,230,950
$1,284,549
$14
$39
$69
$85
$110
$125
$149
$172
$195
$1,284,550
$1,338,049
$14
$39
$69
$85
$110
$125
$149
$172
$1,338,050
$1,391,549
$14
$39
$69
$85
$110
$125
$149
$1,391,550
$1,445,099
$14
$39
$69
$85
$110
$125
$1,445,100
$1,498,599
$14
$39
$69
$85
$110
$1,498,600
$1,552,099
$14
$39
$69
$85
$1,552,100
$1,605,649
$14
$39
$69
$1,605,650
$1,659,199
$14
$39
$1,659,200
$1,712,749
$14
Combined wages between $1,712,750 and $2,248,076
Higher wage
$1,712,750$1,766,250$1,819,800$1,873,300$1,926,800$1,980,350$2,033,900$2,087,400$2,140,900$2,194,500
$1,766,249$1,819,799$1,873,299$1,926,799$1,980,349$2,033,899$2,087,399$2,140,899$2,194,499$2,248,076
$856,300
$909,849
$707
$730
$909,850
$963,399
$707
$730
$753
$777
$963,400
$1,016,899
$707
$730
$753
$777
$800
$823
$1,016,900
$1,070,349
$707
$730
$753
$777
$800
$823
$847
$870
$1,070,350
$1,123,949
$491
$515
$538
$562
$585
$608
$632
$655
$678
$272
$1,123,950
$1,177,449
$265
$289
$312
$336
$359
$382
$406
$429
$452
$474
$1,177,450
$1,230,949
$242
$265
$289
$312
$335
$359
$382
$406
$429
$452
$1,230,950
$1,284,549
$219
$242
$265
$289
$312
$335
$359
$382
$406
$429
$1,284,550
$1,338,049
$195
$219
$242
$265
$289
$312
$336
$359
$382
$406
$1,338,050
$1,391,549
$172
$195
$219
$242
$265
$289
$312
$335
$359
$382
$1,391,550
$1,445,099
$149
$172
$195
$219
$242
$265
$289
$312
$335
$359
$1,445,100
$1,498,599
$125
$149
$172
$195
$219
$242
$265
$289
$312
$335
$1,498,600
$1,552,099
$110
$125
$149
$172
$195
$219
$242
$265
$289
$312
$1,552,100
$1,605,649
$85
$110
$125
$149
$172
$195
$219
$242
$265
$289
$1,605,650
$1,659,199
$69
$85
$110
$125
$149
$172
$195
$219
$242
$265
$1,659,200
$1,712,749
$39
$69
$85
$110
$125
$149
$172
$195
$219
$242
$1,712,750
$1,766,249
$14
$39
$69
$85
$110
$125
$149
$172
$195
$219
$1,766,250
$1,819,799
$14
$39
$69
$85
$110
$125
$149
$172
$195
$1,819,800
$1,873,299
$14
$39
$69
$85
$110
$125
$149
$172
$1,873,300
$1,926,799
$14
$39
$69
$85
$110
$125
$149
$1,926,800
$1,980,349
$14
$39
$69
$85
$110
$125
$1,980,350
$2,033,899
$14
$39
$69
$85
$110
$2,033,900
$2,087,399
$14
$39
$69
$85
$2,087,400
$2,140,899
$14
$39
$69
$2,140,900
$2,194,499
$14
$39
$2,194,500
$2,248,076
$14
Rev. 11/12
2013 School District Income Tax Withholding Instructions
Web site at www.officialpayments.com and select Payment
Center;
 Select Ohio form SD 101 or SD 141;
 Record your credit card payment information for each period.
This packet contains the following:
– Instructions for preparing your school district income tax withholding forms.
– School district income tax withholding forms.
– Computer formula for school district income tax withholding.
Instructions for Employers
1. Requirement to Withhold School District Income Tax
Pursuant to Ohio Revised Code (R.C.) sections 5747.06 and
5747.07, all employers are required to withhold and remit school
district income tax from employees who reside in a school district
that has enacted the school district income tax. Employers should
use the same wage base as they use for Ohio withholding less
the number of exemptions claimed on Ohio form IT 4, Employee’s
Withholding Exemption Certificate (which they keep on file).
Federal Privacy Act Notice
Because we require you to provide us with a Social Security number, the Federal Privacy Act of 1974 requires us to inform you that
providing us with your Social Security number is mandatory. Ohio
Revised Code sections 5703.05, 5703.057 and 5747.08 authorize
us to request this information. We need your Social Security number
in order to administer this tax.
Ohio Business Gateway
The Ohio Business Gateway simplifies tax reporting and payment
for businesses. Now your business can file and pay Ohio and school
district employer’s withholding tax, sales and use tax, unemployment
tax and Workers’ Compensation premiums all at one time! Just go
to tax.ohio.gov, click on Ohio Business Gateway, and you can
start filing your returns online the same day.
Exception: Several school districts have enacted an alternative earned income only tax base. Employers cannot reduce
the wage base for personal exemptions for employees residing
in these school districts. Rather, employers must withhold the
school district tax on all federal wage base compensation paid
to employees residing in these school districts. These earned
income only tax base school districts are included on the enclosed listing.
Registration is simple. Just have your account numbers handy to
start your registration process. You will need your federal employer
identification number or your Social Security number, the legal
name of your company and your e-mail address. You will be asked
to designate a contact person and to list the name and job title of
the person who will be reporting your tax information. You will also
be asked for a user name. Once you’re registered, you can start
filing your returns immediately. On subsequent visits to the Ohio
Business Gateway, you can just log in by entering your user name
and password.
2. Requirement to File Withholding Returns
a. Ohio form SD 101 – Employers must remit payment of the
withheld tax with Ohio form SD 101, Payment of School District Income Tax Withheld, usually on the same due date as
Ohio form IT 501, Employer’s Payment of Ohio Income Tax
Withheld.
b. Ohio form SD 141 – Employers must remit Ohio form SD
141, School District Employer’s Annual Reconciliation of Tax
Withheld.
Credit Card Information – Pay Your Taxes by Credit Card
You can use your Discover/NOVUS, MasterCard or American
Express card to pay your school district income tax liability.
Credit card payments may be made either by telephone by calling
1-800-2PAY-TAX or by visiting www.officialpayments.com and
clicking on the “Payment Center” link.
Note: We encourage you to file these returns electronically
through Ohio Business Gateway at tax.ohio.gov.
3. Completing the Ohio SD 101 Payment Form
All employers are required to file either monthly or quarterly.
a. Quarterly payments are due if the combined Ohio and school
district income tax withholding liability does not exceed
$2,000 during the 12-month period ending on June 30th of
the preceding calendar year.
There is a convenience fee charged for this service. This fee is paid
directly to Official Payments Corporation based on the amount of
your tax payment.
When will my payment be posted? Your payment will be effective
the date you charge it.
What happens if I change my mind? If you pay your tax liability
by credit card and subsequently reverse the credit card transaction,
you may be subject to penalties, interest and other fees imposed by
the Ohio Department of Taxation for nonpayment or late payment
of your tax liability.
b. Monthly payments are due if the combined Ohio and school
district income tax withholding liability exceeds $2,000 during
the 12-month period ending on June 30th of the preceding
calendar year.
Who should I call if I have a problem with my credit card payment? Call Official Payments Corporation toll-free at (866) 621-4109.
Note: School district income tax withholding is not required to
be paid on a partial weekly basis per R.C. section 5747.07.
How do I use my credit card to pay my Ohio withholding tax?
Once you have determined how much you owe:
4. Completing the Ohio SD 101 Payment Form
a. If you have received a preprinted form, listed on your form
are the school district names and numbers for which you have
made previous payments. In the tax due column, please fill in
the amount of tax due for each school district during the period,
or if you are remitting tax for any additional school districts,
write the name, school district number and amount due in the
blank spaces provided on the front of Ohio form SD 101.
 Have your Discover/NOVUS, MasterCard or American Express
card ready;
 Complete lines 1 through 5 on the enclosed worksheet in this
packet;
 Use your touch-tone telephone to call toll-free 1-(800) 2PAY- TAX
or 1-(800) 272-9829; enter 6447 when prompted and follow the
recorded instructions; OR go to the Official Payments Corporation
-1-
If you are not using a preprinted form, fill in each school district
name and number and enter the amount of tax due on the line
next to the school district name(s).
during the year and the underpayment or overpayment. List
each district separately. Please indicate overpayment using
parentheses.
b. Enter the total amount of taxes due for all school districts on
the Total Tax Due line. Unless you pay via the Ohio Business
Gateway or with your credit card, send one check made
payable to School District Income Tax for the total tax due
amount and mail it to School District Income Tax, P.O. Box
182388, Columbus, OH 43218-2388.
b. Bring the total of columns C and D forward and enter these
amounts on lines 1 and 2 of Ohio form SD 141.
c. If line 2 is LESS than line 1, subtract line 2 from line 1 and
enter the balance of school district income tax due (amount
you owe) on line 3. Make your check payable to School District Income Tax.
c. During the calendar year, you may adjust for overpayments
or underpayments by reducing or increasing the tax due for
the same district on a subsequent Ohio form SD 101 filing. Do
not file an amended Ohio form SD 101 return for any period.
d. If line 2 is GREATER than line 1, subtract line 1 from line 2
and enter the overpayment of school district income tax on
line 4.
e. Do not mail paper copies of the wage and tax statements, form
W-2 with Ohio form SD 141. Submit wage and tax statements
only on acceptable magnetic media (e.g., CD-ROM) and send
with your completed Ohio form IT 3, Ohio Transmittal of Wage
and Tax Statement.
Regarding overpayments:
9 Overpayments made for a district can be applied to reduce
the tax due for the same district in a subsequent period, but
cannot be used to reduce the tax due for any other district.
9 Do not show any negative figures. If you show a negative
amount for a district, you are in effect erroneously applying the
overpayment toward the tax that is due for another district.
6. Interest on Unpaid Withheld Tax
School district income tax withheld (or required to be withheld
for each withholding period) and remaining unpaid is subject to
the applicable interest rate per year (3% for 2013).
9 Continue to apply your overpayment for a district toward
the current tax due for the district, until your overpayment
is used up. On Ohio form SD 101, only report amounts that
are currently due. Do not report any tax that is not owed as
a result of an overpayment made for the district in a prior
period.
7. Penalties on Unpaid/Late-Paid Withheld Tax
a. If an employer fails to pay the tax deducted and withheld from
employees’ compensation by the due date, a nonpayment
penalty of 50% may be assessed on the tax due, unless the
employer shows that the failure was for reasonable cause
and not willful neglect.
9 You may keep track of these adjustments by using the School
District Withholding Adjustments Worksheet.
b. If an employer files Ohio form SD 101 and/or Ohio form SD
141 after the due date, a late filing penalty may be assessed,
which is the greater of $50 per month up to a maximum of
$500, or 5% per month up to a maximum of 50% of the tax
due that is required to be shown on the report.
9 If, during the calendar year, you overpay the tax due for a
district on Ohio form SD 101 and you do not have any tax
due for that same district on subsequent periods during the
calendar year, at year-end you can apply on Ohio form SD
141 your overpayment to another school district or claim a
refund of your overpayment.
8. Employee Wage and Tax Statement
Employers must furnish a W-2 form to the employee that identifies both the amount of school district income tax withheld and
the school district (by its four-digit number). Use boxes 19 and
20 on the W-2 or any available area to show this information.
5. Completing Ohio Form SD 141, Employers Annual
Reconciliation of School District Income Tax Withheld
a. You must first complete all columns shown on the lower-half
of Ohio form SD 141. On the lines provided, for each school
district for which you withheld tax, you must list the following
information for each district: the school district name, school
district number, the amount of tax withheld, the amount paid
Caution: Several Ohio school districts have the same name. Be
sure to verify the affected school district by county before withholding for employees.
-2-
Common School District Withholding Questions
Am I required to withhold school district income tax?
Yes, if you...
employ any individual who is a resident of a school district that
has enacted the school district income tax. Place of employment in Ohio does not matter; nor does an out-of-state payroll
office exempt the employer from withholding the taxes. Age
of the employee also does not matter. The only factor is the
employee’s residence in an affected school district.
No, if you...
do not employ in Ohio anyone who is a resident of a school
district with an income tax;
employ any Ohioans in a reciprocity state (Michigan, Pennsylvania, West Virginia, Kentucky or Indiana), and they are residents
of an affected school district.
the taxable wage base (not gross wages) and then allow for Ohio
exemptions to arrive at the amount subject to school district income
tax withholding tax. You may either determine the tax from the Ohio
school district Income tax withholding tables or from the computer
formula on page 4 of this booklet.
Must I withhold if I only have one employee affected?
Yes. If you are conducting business in Ohio and are employing one
or more residents of affected school districts, you must withhold
the school district income tax, no matter how many employees are
affected or how little tax is withheld.
How can my employees find out where they reside?
They may contact their county auditor or use The Finder at tax.
ohio.gov to verify their school district of residence. Should I withhold the school district tax for the 401(k) or
cafeteria plan?
You should use the same taxable wage base that you use for Ohio
withholding and then, unless the employee resides in an earned
income tax base school district, allow for the same Ohio exemptions
claimed on Ohio form IT 4.
How do I show school district withholding tax on my employee’s W-2?
You may use any available box on the W-2 or you may request Ohio
form IT 2, which has specific boxes for school district withholding
tax, and identify the school district by its four-digit number.
How do I register as a school district withholding agent?
If you have not registered as an Ohio employer, you can register
for both Ohio and school district withholding on the Ohio Business
Gateway or check the appropriate box on Ohio form IT 1, Combined
Application for Registration as an Ohio Withholding Tax/School
District Withholding Tax Agent, and send it in. If you are already
registered and have an Ohio withholding account number, please
call our Taxpayer Services Division at 1-888-405-4089 to activate
your Ohio school district withholding account.
Transmittal of wage and tax statements, Ohio form IT 3 – All
employers required to withhold must file with the Ohio Department
of Taxation by the last day of February of the succeeding calendar
year a copy of Ohio form IT 3. Employers are no longer required to
send us paper copies of Ohio form IT 2 or federal form W-2. Send
your state W-2 information to us on magnetic media using an approved electronic format. The electronic format is available on the
department’s Web site at tax.ohio.gov.
Can I include my school district tax payment with my Ohio IT
501?
No. You must remit your school district tax with Ohio form SD
101.
I have no affected employees, but I registered in error. What
do I do?
Write your explanation on the front of the Ohio form SD 101 form
and send it to the address at the top of the form. We will inactivate
your school district account and send you confirmation. To reactivate your account, remit any school district withholding on Ohio
form SD 101.
How do I find out what school district in which each
employee lives?
As an Ohio employer, you should have each employee complete
Ohio form IT 4, Employee’s Withholding Exemption Certificate.
This form will list the employee’s school district residence, and the
employee may update this form whenever there is a change of
residence. You can obtain a copy of the form by visiting our Web
site at tax.ohio.gov.
I no longer have any affected employees. How do I inactivate
my account?
When you file your 2013 annual reconciliation, form SD 141, write
on the front that you no longer have any affected employees. We will
inactivate your account and send you confirmation. If during 2013
you have remitted for any affected employees, you must file a 2013
Ohio form SD 141 at the end of the year and request inactivation
on the front of that form.
Do I file and pay my school district withholding at the same
time as Ohio income tax withholding?
You must use the combined Ohio and school district income tax withholding amounts to determine your filing frequency. If your combined
liability exceeds $2,000 for the 12-month period ending on June 30th
of the preceding calendar year, you must remit your withholding
monthly. If your combined liability does not exceed $2,000 for the
same period, you may remit both taxes quarterly. Electronic funds
transfer withholders remit school district tax monthly.
Are there penalties for not withholding or remitting the
school district tax?
If an employer knows that an employee is subject to the school
district tax but fails to withhold from the employee’s compensation
the appropriate amount of tax, the employer is liable for penalties
and interest. If your return is filed late, a late filing penalty may be
assessed, which is the greater of $50 per month up to $500, or 5%
per month up to 50% of the tax due that is required to be shown on
the report. If the tax was not withheld, the penalty may be twice the
interest charged plus 10% of the delinquent tax payment. If your
payment is late, you may be assessed a late payment penalty of
up to 50% of the delinquent tax payment. The statutory interest
rate for 2013 is 3%.
Where do I send my Ohio SD 101 return and payment?
Send your Ohio SD 101 return and payment to Ohio Department of
Taxation, P.O. Box 182388, Columbus, OH 43218-2388.
My software does not allow for a second local tax. What do I
do?
You must withhold the school district income tax from each affected
employee. You should withhold the tax manually if your software
program does not allow for the school district withholding.
Can I withhold a flat percentage from my employee?
Yes, but only if the employee resides in an earned income tax
base school district. For all of the other employees, you must use
-3-
Computer Formula for School District Income Tax Withholding
Caution: Please see Exception below.
Daily payroll period:
Weekly payroll period:
Biweekly payroll period:
Federal wage base minus $2.50 for each exemption times the
school district tax rate
Federal wage base minus $12.50 for each exemption times the
school district tax rate
Federal wage base minus $25 for each exemption times the
school district tax rate
Semi-monthly payroll period:
Federal wage base minus $27.08 for each exemption times the
school district tax rate
Monthly payroll period:
Federal wage base minus $54.17 for each exemption times the
school district tax rate
Annual payroll period:
Federal wage base minus $650 for each exemption times the
school district tax rate
Exception: Several school districts have enacted an alternative earned income only tax base. Residents of
these school districts are not entitled to the exemption adjustment. Employers must withhold the school
district tax on all federal wage base compensation paid to employees residing in these school districts.
These earned income only tax base school districts are included on the enclosed listing.
IT 4
Rev. 5/07
Employee’s Withholding Exemption Certificate
Print full name
Social Security number
Home address and ZIP code
Public school district of residence
(See The Finder at tax.ohio.gov.)
School district no.
1. Personal exemption for yourself, enter “1” if claimed ..............................................................................................................
2. If married, personal exemption for your spouse if not separately claimed (enter “1” if claimed) .............................................
3. Exemptions for dependents .....................................................................................................................................................
4. Add the exemptions that you have claimed above and enter total ..........................................................................................
5. Additional withholding per pay period under agreement with employer ..............................................................................
$
Under the penalties of perjury, I certify that the number of exemptions claimed on this certificate does not exceed the number to which I am entitled.
Signature
Date
-4-
CLGS-32-6 (8-11)
RESIDENCY CERTIFICATION FORM
Local Earned Income Tax Withholding
TO E M P L O Y E R S / TA X PAY E R S :
This form is to be used by employers and/or taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes.
This form must be utilized by employers when a new employee is hired or when a current employee notifies employer of a name and/or address change.
EMPLOYEE INFORMATION - RESIDENCE LOCATION
NAME (Last Name, First Name, Middle Initial)
SOCIAL SECURITY NUMBER
STREET ADDRESS (No PO Box, RD or RR)
SECOND LINE OF ADDRESS
CITY
STATE
ZIP CODE
DAYTIME PHONE NUMBER
MUNICIPALITY (City, Borough or Township)
COUNTY
RESIDENT PSD CODE
TOTAL RESIDENT EIT RATE
EMPLOYER INFORMATION - EMPLOYMENT LOCATION
EMPLOYER BUSINESS NAME (Use Federal ID Name)
EMPLOYER FEIN
STREET ADDRESS WHERE ABOVE EMPLOYEE REPORTS TO WORK (No PO Box, RD or RR)
SECOND LINE OF ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER
MUNICIPALITY (City, Borough or Township)
COUNTY
WORK LOCATION PSD CODE
WORK LOCATION NON-RESIDENT EIT RATE
CERTIFICATION
Under penalties of perjury, I (we) declare that I (we) have examined this information, including all accompanying
schedules and statements and to the best of my (our) belief, they are true, correct and complete.
SIGNATURE OF EMPLOYEE
PHONE NUMBER
DATE (MM/DD/YYYY)
EMAIL ADDRESS
For information on obtaining the appropriate MUNICIPALITY (City, Borough, Township), PSD CODES and EIT (Earned Income Tax) RATES,
please refer to the Pennsylvania Department of Community & Economic Development website:
www.newPA.com
Form 499 R-4.1
Government of Puerto Rico
Department of the Treasury
Rev. Aug 9 11
WITHHOLDING EXEMPTION CERTIFICATE
READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING THIS WITHHOLDING EXEMPTION CERTIFICATE
Complete this form and submit it to your employer. Otherwise, the employer is required to withhold your income taxes without taking into consideration your
personal exemption, exemption for dependents and allowance based on deductions, pursuant to the Internal Revenue Code for a New Puerto Rico (Code).
ANY CHANGES IN THE PERSONAL EXEMPTION, THE NUMBER OF DEPENDENTS OR THE ALLOWANCE BASED ON DEDUCTIONS, REQUIRE THE FILING OF AN AMENDED CERTIFICATE.
Employee’s name
FOR EMPLOYEE’S USE ONLY
Employee’s social security number
Spouse’s name
Spouse’s social security number
Home address
Postal address
Check here if your annual gross wages do not exceed $20,000. If you want your employer to withhold income taxes on your wages, complete Part D.
Otherwise, proceed to sign this Certificate.
Check here if you choose the provisions of the Military Spouses Residency Relief Act. (See instructions)
Check here if you choose the optional computation of tax in the case of married individuals living together and filing a joint return. (See instructions)
None
Complete
Half
A. PERSONAL EXEMPTION
(less withholding)
(more withholding)
1. Individual taxpayer………………..........................................................……
2. Married person …………………...………..........................................…….…
3. Additional veterans personal exemption …….….......................................…..
B. EXEMPTION FOR DEPENDENTS: Number of Dependents
Complete Exemption
Joint Custody
C. ALLOWANCE BASED ON DEDUCTIONS
Complete
1. ALLOWANCE BASED ON THE SPECIAL DEDUCTION FOR CERTAIN INDIVIDUALS (See instructions)
2. ALLOWANCE BASED ON DEDUCTIONS (OPTIONAL):
(a) Home mortgage interest ……………………………………………………..................................................……............…
(b) Charitable contributions ……………………………………………………………………………...............................……
(c) Medical expenses …………………………………………………………………………………................................……
(d) Interest paid on student loans at university level …...………………………………………………………..................……
(e) Contributions to governmental pension or retirement systems (See instructions) …………………………….................….
(f) Contributions to Individual Retirement Accounts ……………………………………………………………..............………
(g) Educational Contributions Account …………………………………………………………………………...................……
(h) Contributions to health savings accounts ……………………………………………………………......................……....…
(i) Casualty loss on your principal residence ………………………………………………………………………............……
(j) Loss of personal property as a result of certain casualties ……………………………………………..............……………
(k) Total deductions ...........................…………………………………………………………………................………
3. Number of allowances based on deductions (Divide line 2(k) by $500) ................................................................…........….
4. Allowances that you want to claim (May be less or equal to line 3) ……...……………………………………………..........………
None
00
00
00
00
00
00
00
00
00
00
00
If you are a governmental employee, mark to indicate if you participate in any of the following programs (See instructions):
Retirement Withholding Supplementary Plan
Retirement Savings Accounts Program (Indicate the percentage that you elected as contribution ______%)
D. ELECTION FOR ADDITIONAL WITHHOLDING
I authorize my employer to withhold in each payroll period the amount of $________ or ______ % from my wages in addition to the tax required to be
deducted and withheld according to the provisions of Section 1062.01 of the Code. (See instructions)
OATH
I declare under the penalty of perjury that I have examined this form, and to the best of my knowledge, the information contained herein is true, correct and complete.
I also certify that the personal exemption, exemption for dependents and the allowance based on deductions claimed herein, for purposes of withholding of income
tax on wages, do not exceed the amount that I am entitled to claim on the income tax return, according to the Code.
___________________________________
Employee’s signature
_________________
Date
Retention Period: Six (6) years
INSTRUCTIONS
The Withholding Exemption Certificate (Form 499 R-4.1) is the document used by the
employee to notify his/her employer of the personal exemption, exemption for dependents
and the allowance based on deductions. These three factors are considered to determine
the income tax to be withheld from the employee’s wages.
Complete the upper part of the form, indicating your name, social security number,
postal and home address.
If your annual gross wages do not exceed $20,000, the same will not be subject to
withholding at source. Nevertheless, you may elect for the employer to make withholding
of income tax according to the amount or percentage indicated in Part D of this Certificate.
Enter on lines 2(a) through 2(j), the amount of these deductions that you estimate you will be
entitled to claim on your return. Such deductions are subject to the limitations and requirements
provided in Section 1033.15 of the Code.
If you are married and choose the optional computation, the number of allowances shall
be determined by dividing the deductions among the spouses. In the case of home mortgage
interest, charitable contributions, medical expenses, and loss on your principal residence or
personal property as a result of certain casualties, include 50% of each deduction. In the case
of contributions to governmental pension or retirement systems, Individual Retirement
Accounts, Educational Contribution Accounts, Health Savings Accounts and interest paid on
student loans at university level, include the amount that corresponds individually.
Under the Military Spouses Residency Relief Act (MSRRS), if you are the spouse of an
active service member that was transferred under military orders to a new military station in
any of the states, possessions or territories of the United States or the District of Columbia,
you can keep your original residence or domicile for tax purposes. Indicate if you elect this
option so that the employer will not be required to withhold income tax for Puerto Rico.
Nevertheless, you may be subject to the payment of federal estimated tax or from the state,
possession or territory for which you elected to keep as your residence or the employer
may withhold federal, local or state taxes, as applicable.
Line 2(e) – If you are a governmental employee, you shall consider the governmental
pension or retirement plan to which you make contributions, if any:
If you are married, include you spouse’s name and social security number, and indicate
if you choose the optional computation of tax in the case of married individuals living
together and filing a joint return (optional computation), as provided by Section
1021.03 of the Internal Revenue Code for a New Puerto Rico (Code).
the other hand, if you are a governmental employee who makes contributions
· On
through the Retirement Savings Accounts Program, you shall consider 8.275%, 9%,
PART A - PERSONAL EXEMPTION
Indicate with an “X” your option regarding the personal exemption that your employer
will consider to determine the income tax to be withheld.
Line 1 – An individual taxpayer (single person, married that granted prenuptial agreement
of total separation of assets or married not living with spouse) may claim or not the
personal exemption. If you want to claim the complete personal exemption, mark the
column titled “Complete”. On the other hand, if you choose to claim no exemption at all,
you may do so by marking the column titled “None”. An individual taxpayer cannot
choose to consider “Half” of his/her personal exemption.
Line 2 - Married couples are entitled to only one personal exemption, therefore, each
spouse cannot claim the complete personal exemption. If you are a married person, and
both spouses receive wages subject to withholding, both of you should agree on how
to claim the personal exemption and shall mark the corresponding column. If the
married couple determines that only one of them will consider the complete personal
exemption, such spouse shall mark the column titled “Complete”. In such case, the
other spouse shall mark the column titled “None”. If you agreed with your spouse to
divide the personal exemption in half, indicate so marking the column titled “Half”. If you
do not want to claim the personal exemption, mark the column titled “None”.
If you are married and choose the optional computation, the personal exemption will
be considered on a 50% basis for each spouse. Therefore, each spouse may choose
to consider the complete personal exemption or no personal exemption at all regarding
this 50%.
Line 3 – Every veteran is entitled to claim an additional personal exemption. The
veteran may claim the complete additional personal exemption or may choose to claim
no additional personal exemption at all.
PART B - EXEMPTION FOR DEPENDENTS
Indicate the number of dependents that will be considered for the withholding computation.
It shall be the same as the number that you will claim as dependents on your income
tax return. Indicate separately in the corresponding box, the children for which you are
entitled to joint custody and have not released the claim to exemption. In these cases,
only 50% of the exemption will be considered.
If you are an employee who elected the optional computation, your exemption for
dependents will be 50% of the total amount provided by Section 1033.18(b) of the Code,
since in such cases each spouse is entitled to claim only half of the exemption for
dependents, as provided in Section 1021.03 of the Code.
The Code provides that every employer, who receives an exemption certificate from
an employee in which the number of dependents claimed exceeds 8, shall submit
a copy of such certificate to the Secretary of the Treasury, as well as a copy of any
written statement received from the employee to support the information contained in the
certificate.
PART C - ALLOWANCE BASED ON DEDUCTIONS
You are entitled to certain allowances based on deductions which your employer shall
consider to determine the amount of income tax to be withheld.
Line 1 – The number of allowances under the special deduction for certain individuals
is subject to the limitations and requirements provided by Section 1033.16 of the Code.
This deduction shall be available to those individuals whose gross income does not
exceed $20,000, providing that for each dollar of gross income in excess of $20,000,
the allowable deduction shall be reduced by fifty cents until it is reduced to zero.
If you choose to consider the special deduction, mark the box titled “Complete”. On the
other hand, if you choose to claim no special deduction at all, you shall mark the box
titled “None”.
Line 2 – You have the option to consider in the withholding computation, the deductions
that you will be able to claim on your income tax return. Such deductions will reduce the
amount of tax that the employer will withhold on your wages. If you do not wish to
consider these deductions in the computation, do not complete this line.
you make contributions to the governmental pension or retirement plan, you shall
· Ifconsider
8.275% of your annual wages.
elected the supplementary retirement plan, then, you shall consider 5.775% of
· Ifyouryoumonthly
wages up to $550 and 8.275% of your monthly wages in excess of such
amount (on an annual basis).
9.5%, or 10% (as elected) of your annual wages.
If you are a governmental employee, who works for an agency which payroll is
processed by the Department of the Treasury, do not consider your contributions to
the pension or retirement system on this line. This deduction will automatically be
considered in the withholding computation.
Line 3 – Divide the amount figured on line 2(k) by $500. Any fraction obtained as a result of
the preceding division exceeding 50%, shall be considered as an additional allowance.
Line 4 – Indicate the allowances that you wish to claim, from the amount determined on line
3. If you file as a married person living with spouse and do not choose the optional
computation, you and your spouse shall be allowed to divide the total allowances as you
wish, but based on complete allowances. However, any allowance considered by one
spouse cannot be claimed by the other spouse.
PART D – ELECTION FOR ADDITIONAL WITHHOLDING
Any employee may elect for his/her employer to withhold an amount in addition to the one
required by Section 1062.01(e) of the Code. Under no circumstances, this option will be
allowed for an amount less than the tax determined according to the withholding tables
approved by the Secretary based on the tax rates provided by the Code. Also, this option
may be exercised by every employee whose annual gross wages do not exceed $20,000
and chooses for the withholding to be made on such wages.
OATH
You declare under penalty of perjury, that you have examined this form, and that to the best
of your knowledge, the information contained therein is true, correct and complete.
SIGNATURE
This form must be signed and dated by the employee.
PENALTIES
Any employee required to submit a withholding exemption certificate to his/her employer,
who willfully provides false or fraudulent information, or who willfully fails to provide information
which would require an increase in the tax to be withheld, shall be guilty of a misdemeanor
as provided in Section 6041.08 of the Code.
In the case of employees who elect to consider the allowance for deductions provided in
Section 1062.01(c)(2)(A)(ii) of the Code, in addition to the criminal penalty mentioned in the
above paragraph, if 70% of the tax attributable to income derived from wages subject to
withholding exceeds the tax withheld at source on said income, there shall be added to the
tax the smaller of: (1) an amount equal to such excess, or (2) an amount equal to 18% of the
amount for which such tax so determined exceeds the tax withheld.
INSTRUCTIONS TO THE EMPLOYER
The employer shall consider the information provided by the employee on this Certificate with
respect to the personal exemption, exemption for dependents and allowance based on
deductions in order to make the withholding according to the Employer’s Guide on the
Withholding of Income Tax at Source on Wages for the corresponding taxable year.
If the employee’s annual gross wages do not exceed $20,000, such wages are not subject
to withholding at source, unless the employee had completed the election, in Part D, for the
additional withholding to be made.
If the employee elects the provisions of the MSRRA, no withholding of tax at source on
wages shall be made for Puerto Rico purposes. Nevertheless, such wages may be subject
to withholding of federal taxes according to the provisions of the Internal Revenue Service.
If the number of dependents exceeds 8, submit copy of this Certificate to the Fiscal Audit
Bureau, as well as copy of any written statement received from the employee to support the
information contained in the certificate.
FORM VA-4
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF TAXATION
PERSONAL EXEMPTION WORKSHEET
(See back for instructions)
1.If you wish to claim yourself, write “1”............................................................... ________________
2.If you are married and your spouse is not claimed
on his or her own certificate, write “1”................................................................ ________________
3.Write the number of dependents you will be allowed to claim
on your income tax return (do not include your spouse).................................... ________________
4.Subtotal Personal Exemptions (add lines 1 through 3)...................................... ________________
5.Exemptions for age
(a)
_If you will be 65 or older on January 1, write “1”................................... ________________
(b)
_If you claimed an exemption on line 2 and your spouse
_will be 65 or older on January 1, write “1”............................................. ________________
6.Exemptions for blindness
(a)
_If you are legally blind, write “1”............................................................ ________________
(b)
_If you claimed an exemption on line 2 and your
_spouse is legally blind, write “1”............................................................ ________________
7.Subtotal exemptions for age and blindness (add lines 5 through 6)...................................................._______________
8.Total of Exemptions - add line 4 and line 7.........................................................................................._______________
Detach here and give the certificate to your employer. Keep the top portion for your records
FORM VA-4 EMPLOYEE’S VIRGINIA INCOME TAX WITHHOLDING EXEMPTION CERTIFICATE
Your Social Security Number
Name
Street Address
City
State
Zip Code
COMPLETE THE APPLICABLE LINES BELOW
1.If subject to withholding, enter the number of exemptions claimed on:
(a)Subtotal of Personal Exemptions - line 4 of the
Personal Exemption Worksheet............................................................................................
(b)Subtotal of Exemptions for Age and Blindness
line 7 of the Personal Exemption Worksheet........................................................................
(c)Total Exemptions - line 8 of the Personal Exemption Worksheet.........................................
2.Enter the amount of additional withholding requested (see instructions)...........................................
.
2601064 Rev. 08/11
3.I certify that I am not subject to Virginia withholding. l meet the conditions
set forth in the instructions .................................................................................. (check here)
4.I certify that I am not subject to Virginia withholding. l meet the conditions set forth
Under the Service member Civil Relief Act, as amended by the Military Spouses
Residency Relief Act ........................................................................................... (check here)
Signature
Date
EMPLOYER: Keep exemption certificates with your records. If you believe the employee has claimed too many exemptions, notify the Department of
Taxation, P.O. Box 1115, Richmond, Virginia 23218-1115, telephone (804) 367-8037. Note: Employers may establish a system to electronically receive
Forms VA-4 from employees, provided the system meets Internal Revenue Service requirements as specified in § 31.3402(f)(5)-1(c) of the Treasury
Regulations (26 CFR).
FORM VA-4 INSTRUCTIONS
Use this form to notify your employer whether you are subject to Virginia income tax withholding and how many
exemptions you are allowed to claim. You must file this form with your employer when your employment begins. If you
do not file this form, your employer must withhold Virginia income tax as if you had no exemptions.
PERSONAL EXEMPTION WORKSHEET
You may not claim more personal exemptions on form VA-4 than you are allowed to claim on your income
tax return unless you have received written permission to do so from the Department of Taxation.
Line 1. You may claim an exemption for yourself.
Line 2. You may claim an exemption for your spouse if he or she is not already claimed on his or her own certificate.
Line 3. Enter the number of dependents you are allowed to claim on your income tax return.
NOTE: A spouse is not a dependent.
Line 5. If you will be age 65 or over by January 1, you may claim one exemption on Line 5(a). If you claim an exemption for your spouse on Line 2, and your spouse will also be age 65 or over by January 1, you may claim an additional exemption on Line 5(b).
Line 6. If you are legally blind, you may claim an exemption on Line 6(a). If you claimed an exemption for your spouse on Line 2, and your spouse is legally blind, you may claim an exemption on Line 6(b).
FORM VA-4
Be sure to enter your social security number, name and address in the spaces provided.
Line 1. If you are subject to withholding, enter the number of exemptions from:
(a) Subtotal of Personal Exemptions - line 4 of the Personal Exemption Worksheet
(b) Subtotal of Exemptions for Age and Blindness - line 7 of the Personal Exemption Worksheet
(c) Total Exemptions - line 8 of the Personal Exemption Worksheet
Line 2. If you wish to have additional tax withheld, and your employer has agreed to do so, enter the amount of additional tax on this line.
Line 3. If you are not subject to Virginia withholding, check the box on this line. You are not subject to withholding if you meet any one of the conditions listed below. Form VA-4 must be filed with your employer for each calendar year for which you claim exemption from Virginia withholding.
(a) You had no liability for Virginia income tax last year and you do not expect to have any liability for this year.
(b) You expect your Virginia adjusted gross income to be less than the amount shown below for your filing status:
Taxable Years Taxable Years Taxable Years Taxable Years
2005, 2006
2008 and
2010 and
2012 and
and 2007
2009
2011
Beyond
Single
$7,000
$11,250
$11,650
$11,950
Married
$14,000
$22,500
$23,300
$23,900
Married, filing a separate
return
$7,000
$11,250
$11,650
$11,950
(c) You live in Kentucky or the District of Columbia and commute on a daily basis to your place of employment in Virginia.
(d) You are a domiciliary or legal resident of Maryland, Pennsylvania or West Virginia whose only Virginia source income is from salaries and wages and such salaries and wages are subject to income taxation by your state of domicile.
Line 4. Under the Servicemember Civil Relief Act, as amended by the Military Spouses Residency Relief Act, you may
be exempt from Virginia income tax on your wages if (i) your spouse is a member of the armed forces present
in Virginia in compliance with military orders; (ii) you are present in Virginia solely to be with your spouse; and
(iii) you maintain your domicile in another state. If you claim exemption under the SCRA check the box on Line
4 and attach a copy of your spousal military identification card to Form VA-4.
Instructions for completing Form W-4VT
Who must complete Form W-4VT:
• Any person whose employer requires this form
• Any person requiring Vermont Withholding to be based on W-4 information which is different from the
Federal W-4. This would include employees anticipating Child Tax Credit, Hope Credit, or other federal
credits which do not pass through to Vermont income tax and employees who are in civil unions.
Completing Form W-4VT: This form is completed in the same manner as the Federal W-4. Complete the federal W4 form first, following the instructions on the form or IRS Publication 919, How Do I Adjust My Tax
Withholding?.
Parts 1 and 2: Print or type your Name and Social Security Number. For taxpayers using the fillable
PDF, type in the Social Security Number without hyphens.
Part 3:
Enter any information required by your employer.
If you are a partner in a civil union, check either “Civil Union” or Civil Union, but
withhold at the higher Single rate”. Otherwise check the filing status used on the Federal
b. Enter the number of allowances for Vermont withholding. If you claimed additional
allowances for Federal tax because of anticipated child credit or education credit, do not
claim these additional allowances for Vermont withholding.
c. If you want an additional amount of Vermont withholding to be deducted from each
paycheck, enter amount.
Part 5: Sign and date the form. Send completed forms to Payroll Division either by fax to 828-2435;
email to: [email protected]; or mail to 109 State Street, 4th Fl, Montpelier 05609-1501
Part 4: a. This form may be photocopied as needed.
W-4VT
Part 1
State of Vermont Department of Taxes
Vermont Employee's Withholding Allowance Certificate
First Name
Part 3
Part 4
Initial
Part 2
Last Name
Social Security Number
Employee Number:
(or other employer information required by employer)
a. Is your Vermont filing status:
Single
Married
Civil Union
Married, but withhold at the higher Single rate
Civil Union, but withhold at the higher Single Rate
NOTE: If married, but legally separated, or spouse is a nonresident alien, check the 'Single' box.
b. Total number of Vermont Withholding allowances …………..………………….......…b.
If you claimed additional allowances for Federal tax because of anticpated child credit or education credit,
do not claim these additional allowances for Vermont withholding.
c. Additional amount, if any, of Vermont Tax to be withheld from each paycheck………..c.
d.
I Claim exemption from withholding for 2013, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all state income tax withheld because I had no tax liability, and
• This year I expect a refund of all state income tax withheld because I expect to have no tax liability.
If you meet both conditions, than you may write 'EXEMPT' here............................................▶
Part 5
I certify that I am entitled to the number of withholding allowances claimed on this certificate.
Signature
Date
$
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Employee’s Wisconsin Withholding Exemption Certificate/New Hire Reporting
WT-4
Employee’s Section (Print clearly)
Employee’s legal name (last, first, middle initial)
Social security number
Employee’s address (number and street)
Date of birth
City
State
Zip code
Single
Married
Married, but withhold at higher Single
rate.
Note: If married, but legally separated,
check the Single box.
Date of hire
FIGURE YOUR TOTAL WITHHOLDING EXEMPTIONS BELOW
Complete Lines 1 through 3 only if your Wisconsin exemptions are different than your federal allowances.
1. (a) Exemption for yourself – enter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (b) Exemption for your spouse – enter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (c) Exemption(s) for dependent(s) – you are entitled to claim an exemption for each dependent . . . . . . . . (d) Total – add lines (a) through (c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Additional amount per pay period you want deducted (if your employer agrees) . . . . . . . . . . . . . . . . . . . . . . 3. I claim complete exemption from withholding (see instructions). Enter “Exempt” . . . . . . . . . . . . . . . . . . . . . I CERTIFY that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled. If claiming complete exemption from
withholding, I certify that I incurred no liability for Wisconsin income tax for last year and that I anticipate that I will incur no liability for Wisconsin income tax for this year.
Signature
Date Signed
,
EMPLOYEE INSTRUCTIONS:
WT-4 Instructions – Provide your information in the employee section.
• WHO MUST FILE:
Every Employee is required to file a completed Form WT-4 with each
of his or her employers unless the Employee claims the same number
of withholding exemptions for Wisconsin withholding tax purpose as for
federal withholding tax purpose. Form WT-4 (or federal Form W-4 if a
Form WT-4 is not filed) will be used by your employer to determine the
amount of Wisconsin income tax to be withheld from your paychecks. If
you have more than one employer, you should claim a smaller number or
no exemptions on each Form WT-4 filed with employers other than your
principal employer so that the total amount withheld will be closer to your
actual income tax liability.
• LINE 1:
(a)-(c) Number of exemptions – Do not claim more than the correct number
of exemptions. If you expect to owe more income tax for the year than will
be withheld if you claim every exemption to which you are entitled, you may
increase your withholding by claiming a smaller number of exemptions on
lines 1(a)‑(c) or you may enter into an agreement with your employer to have
additional amounts withheld (see instruction for line 2).
Your employer may also require you to complete this form to report your
hiring to the Department of Workforce Development.
You may file a new Form WT-4 any time you wish to change the amount
of withholding from your paychecks, providing the number of exemptions
you claim does not exceed the number you are entitled to claim.
• UNDER WITHHOLDING:
If sufficient tax is not withheld from your wages, you may incur additional
interest charges under the tax laws. In general, 90% of the net tax shown
on your income tax return should be withheld.
• OVER WITHHOLDING:
If you are using Form WT-4 to claim the maximum number of exemptions
to which you are entitled and your withholding exceeds your expected
income tax liability, you may use Form WT-4A to minimize the over
withholding.
• WHEN TO FILE IF YOUR EXEMPTIONS CHANGE:
You must file a new certificate within 10 days if the number of exemptions
previously claimed by you DECREASES.
You may file a new certificate at any time if the number of your exemptions
INCREASES.
(c) Dependents – Those persons who qualify as your dependents for federal
income tax purposes may also be claimed as dependents for Wisconsin
purposes. The term “dependents” does not include you or your spouse. Indicate the number of dependents that you are claiming in the space provided.
• LINE 2:
Additional withholding – If you have claimed “zero” exemptions on line 1, but
still expect to have a balance due on your tax return for the year, you may
wish to request your employer to withhold an additional amount of tax for each
pay period. If your employer agrees to this additional withholding, enter the
additional amount you want deducted from each of your paychecks on line 2.
• LINE 3:
Exemption from withholding – You may claim exemption from withholding of
Wisconsin income tax if you had no liability for income tax for last year, and
you expect to incur no liability for income tax for this year. You may not claim
exemption if your return shows tax liability before the allowance of any credit
for income tax withheld. If you are exempt, your employer will not withhold
Wisconsin income tax from your wages.
You must revoke this exemption (1) within 10 days from the time you expect
to incur income tax liability for the year or (2) on or before December 1 if you
expect to incur Wisconsin income tax liabilities for the next year. If you want to
stop or are required to revoke this exemption, you must file a new Form WT‑4
with your employer showing the number of withholding exemptions you are
entitled to claim. This certificate for exemption from withholding will expire on
April 30 of next year unless a new Form WT‑4 is filed before that date.
Employer’s Section
Employer’s name
Federal Employer ID Number
Employer’s payroll address (number and street)
Completed by
City
Title
State
Phone number
(
)
Zip code
Email
EMPLOYER INSTRUCTIONS for Department of Revenue:
EMPLOYER INSTRUCTIONS for New Hire Reporting:
• If you do not have a Federal Employer Identification Number (FEIN), contact
the Internal Revenue Service to obtain a FEIN.
• This report contains the required information for reporting a New Hire to
Wisconsin. If you are reporting new hires electronically, you do not need to
forward a copy of this report to the Department of Workforce Development.
Visit http://dwd.wisconsin.gov/uinh to report new hires.
• If the Employee has claimed more than 10 exemptions OR has claimed
complete exemption from withholding and earns more than $200.00 a week
or is believed to have claimed more exemptions than he or she is entitled to,
mail a copy of this certificate to: Wisconsin Department of Revenue, Audit
Bureau, PO Box 8906, Madison WI 53708 or fax (608) 267‑0834.
• Keep a copy of this certificate with your records. If you have questions about the
Department of Revenue requirements, call (608) 266‑8646 or (608) 266‑2776.
W-204 (R. 1-14)
• If you do not report new hires electronically, mail the original form to the Depart‑
ment of Workforce Development, New Hire Reporting, PO Box 14431, Madison
WI 53708-0431 or fax toll free to 1‑800‑277‑8075.
• If you have questions about New Hire requirements, call toll free (888) 300‑HIRE
(888‑300‑4473). Visit dwd.wisconsin.gov/uinh for more information.
Wisconsin Department of Revenue
The address will be displayed appropriately in a left window envelope.
DEPARTMENT OF WORKFORCE DEVELOPMENT
NEW HIRE REPORTING
PO BOX 14431
MADISON WI 53708-0431
WEST VIRGINIA EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE
FORM WV/IT-104
Complete this form and present it to your employer to avoid any delay in adjusting the amount of state
income tax to be withheld from your wages.
If you do not complete this form, the amount of tax that is now being withheld from your pay may not be
sufficient to cover the total amount of tax due the state when filing your personal income tax return after the
close of the year. You may be subject to a penalty on tax owed the state.
Individuals are permitted a maximum of one exemption for themselves, plus an additional exemption for
their spouse and any dependent other than their spouse that they expect to claim on their tax return.
If you are married and both you and your spouse work and you file a joint income tax return, or
if you are working two or more jobs, the revised withholding tables should result in a more accurate
amount of tax being withheld.
If you are Single, Head of Household, or Married and your spouse does not work, and you are receiving
wages from only one job, and you wish to have your tax withheld at a lower rate, you must check the box on
line 5.
When requesting withholding from pension and annuity payments you must present this completed form
to the payor. Enter the amount you want withheld on line 6.
If you determine the amount of tax being withheld is insufficient, you may reduce the number of
exemptions you are claiming or request additional taxes be withheld from each payroll period. Enter the
additional amount you want to have withheld on line 6.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - cut here- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
WV/IT-104
Rev. 12/09
WEST VIRGINIA EMPLOYEEE’S WITHHOLDING EXEMPTION CERTIFICATE
Name________________________________________
Social Security Number ____________________________________
Address________________________________________________________________________________________________________
City________________________________________
State_____________________
Zip Code ____________________
1.
If SINGLE, and you claim an exemption, enter “1”, if you do not, enter “0 ..........................................
2.
If MARRIED, one exemption each for husband and wife if not claimed on another certificate.
(a) If you claim both of these exemptions, enter “2”
(b) If you claim one of these exemptions, enter “1”
........................................
(c) If you claim neither of these exemptions, enter “0”
3.
If you claim exemptions for one or more dependents, enter the number of such exemptions. ...........
4.
Add the number of exemptions which you have claimed above and enter the total ............................
5.
If you are Single, Head of Household, or Married and your spouse does not work, and you are receiving
wages from only one job, and you wish to have your tax withheld at a lower rate, check here ...........
6.
Additional withholding per pay period under agreement with employer, enter amount here .............. $
Note that special withholding allowances provided on Federal Form W-4 may not be claimed on your West Virginia Form WV/IT-104 I CERTIFY,
under penalties provided by law, that the number of exemptions claimed in this certificate is not in excess of those to which I am entitled.
Date__________________________
Signature____________________________________________
NONRESIDENTS-SEE REVERSE SIDE