Form B-117 - Request For Change Of Income Tax Withholding Status

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Vermont Department of Labor
REQUEST FOR CHANGE OF
INCOME TAX WITHHOLDING STATUS
ID # ____
I wish to request a change of my income tax withholding status. I understand that this change
is not retroactive, but will only affect claims filed after the date of this authorization.
I elect to have taxes withheld from my Unemployment Insurance check.
I understand a total of 10% of my gross weekly Unemployment amount will
be deducted for federal tax. In addition, I understand that 24% of my
federal withholding amount will be withheld for State of Vermont tax withholding.
I wish to stop deductions of federal and state tax from my weekly
Unemployment checks.
I understand that this change is final and must remain in effect for the remainder of my
existing benefit year.
Signature: _________________________________
Date: ____________________
RETURN TO:
Vermont Department of Labor
P.O. Box 189
Montpelier, VT 05601-0189
or
Fax the form to the department at
802-828-9191
B-117 (7/06)

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