Form 499 R-4.1 - Withholding Exemption Certificate Form - Commonwealth Of Puerto Rico Department Of The Treasury
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1
2Commonwealth of Puerto Rico
Form 499 R-4.1
Rev. 11.03
Department of the Treasury
WITHHOLDING EXEMPTION CERTIFICATE
FOR EMPLOYEE'S USE
READ INSTRUCTIONS ON REVERSE SIDE BEFORE FILLING OUT THIS WITHHOLDING EXEMPTION CERTIFICATE
Fill out this form and file it with your employer. Otherwise, said employer is required by the Puerto Rico Internal Revenue Code of
1994, as amended (Code), to withhold your income tax without taking into account your personal exemption, exemption for
dependents and allowance based on deductions.
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 social security number
Employee's name
Spouse's social security number
Spouse's name
Home address
Postal address
Complete
Half
None
A.
PERSONAL EXEMPTION
1.
Single or married not living with spouse
2.
Married person
3.
Head of household
B.
EXEMPTION FOR DEPENDENTS
NUMBER OF DEPENDENTS: _______________________
Automatic Method
C.
ALLOWANCE BASED
Optional
ON DEDUCTIONS
Complete
None
Method
1.
Private business employee
*
2.
Governmental employee
*
If you are a governmental employee, you must make a check mark to indicate if you participate in any of the
following programs:
;
Withholding Supplementary Plan for Retirement
;
Savings Accounts Program for Retirement. (Indicate the percentage that you elected as contribution ______%)
OATH
I HEREBY CERTIFY that the personal exemption, exemption for dependents and the allowance based on deductions claimed herein, for purposes
of withholding of income tax from wages, do not exceed the amount that I am entitled to claim on the income tax return, according with the Code.
___________________________________
_________________
Employee's signature
Date
FOR EMPLOYER'S USE
Indicate the number of allowances according to the method selected by the employee in Part C: ______________
(See instructions on back)
Conservation Period: Six (6) years
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