Form Ct-W4 - Employee Withholding Allowance Certificate - 2015

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Department of Revenue Services
Form CT-W4
Effective January 1, 2015
State of Connecticut
Employee’s Withholding Certifi cate
(Rev.
)
08/15
Complete this form in blue or black ink only.
Employee Instructions
• Read instructions on Page 2 before completing this form.
• Choose the statement that best describes your gross income.
• Select the fi ling status you expect to report on your Connecticut
• Enter the Withholding Code on Line 1 below.
income tax return. See instructions.
Withholding
Married Filing Separately
Code
Withholding
Married Filing Jointly
My expected annual gross income is less than or equal to
Code
E
$12,000 or I am claiming exemption under the MSRRA* and
Our expected combined annual gross income is less than or
no withholding is necessary.
equal to $24,000 or I am claiming exemption under the Military
E
A
Spouses Residency Relief Act (MSRRA)* and no withholding
My expected annual gross income is greater than $12,000.
is necessary.
I have signifi cant nonwage income and wish to avoid having
D
My spouse is employed and our expected combined annual
too little tax withheld.
A
gross income is greater than $24,000 and less than or equal
D
I am a nonresident of Connecticut with substantial other income.
to $100,500. See Certain Married Individuals, Page 2.
Withholding
My spouse is not employed and our expected combined
Single
C
Code
annual gross income is greater than $24,000.
My expected annual gross income is less than or equal to
E
My spouse is employed and our expected combined
$14,500 and no withholding is necessary.
D
annual gross income is greater than $100,500.
F
My expected annual gross income is greater than $14,500.
I have signifi cant nonwage income and wish to avoid having
D
I have signifi cant nonwage income and wish to avoid having
too little tax withheld.
D
too little tax withheld.
I am a nonresident of Connecticut with substantial other income.
D
D
I am a nonresident of Connecticut with substantial other income.
Withholding
Qualifying Widow(er) With Dependent Child
Code
Withholding
Head of Household
Code
My expected annual gross income is less than or equal to
E
My expected annual gross income is less than or equal to
$24,000 or I am claiming exemption under the MSRRA* and
E
no withholding is necessary.
$19,000 and no withholding is necessary.
B
C
My expected annual gross income is greater than $19,000.
My expected annual gross income is greater than $24,000.
I have signifi cant nonwage income and wish to avoid having
I have signifi cant nonwage income and wish to avoid having too
D
D
too little tax withheld.
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.
* 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.
1. Withholding Code: Enter Withholding Code letter chosen from above. ....................... 1.
Check if you are claiming
the
MSRRA exemption
and enter state of legal
2. Additional withholding amount per pay period: If any, see Page 3 instructions. . ......... 2. $
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 certifi cate 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 fi ne of not more than $5,000, imprisonment for not more than fi ve years, or both.
Employee’s signature
Date
Employers: See
Employer Instructions on Page 2.
 No
 Yes  Enter date hired:
Is this a new or rehired employee?
mm/dd/yyyy
Employer’s business name
Federal Employer Identifi cation Number
Employer’s business address
City/town
State
ZIP code
Contact person
Telephone number
(
)

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