Form De 4s - Request For State Income Tax Withholding From Sick Pay
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1Request for State Income Tax
Withholding From Sick Pay
0B
File this form with the payer of your sick pay.
Type or Print Your Full Name
Your Social Security Number
Home Address (Number and Street or Rural Route)
City or Town, State, and ZIP Code
Claim or Identification Number (If Any)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
I request income tax withholding from my sick pay payments. I want the following amount to be withheld from each payment
. . . . . .
Employee’s Signature
Date
Detach along this line. Give the top part of this form to the payer; keep the lower part for your records
----------------------------------------------------
. -------------------------------------------------
General Instructions
The Information Practices Act Notice: Information
Amount to Be Withheld: Enter on this form the
collected is for the purpose of administering the
amount you want withheld from each payment.
Personal Income Tax law under the authority of
You can use the worksheet accompanying the state
Section 13028.6 of the
California Unemployment
Employee's Withholding Allowance Certificate
Insurance Code
and Section 4328.6-1 of
Title
22,
(DE
4) to estimate the amount of income tax you
California Code of Regulations.
want withheld from each sick pay payment.
Purpose of Form: To request state income tax
Sign This Form: The DE 4S is not valid unless you
withholding from sick pay. File this form ONLY if
sign it.
the sick pay is received from a third party, such as
an insurance company or trust. You do not have to
Statement of Income Tax Withheld: After the end
file this form if you receive sick pay from your
of the year, you will receive a Wage and Tax
employer as you have previously submitted a
Statement (Form W-2) reporting the taxable sick
withholding form.
pay paid and income tax withheld during the prior
year. These amounts may be included on your
You may not want to use the DE 4S form if you
Form W-2 with your other wages and withholding.
already have all your tax liability covered by
estimated tax payments or other withholding.
Changing Your Withholding: The DE 4S remains
in effect until you change or cancel it. You can do
Definition: Sick pay is a payment you receive:
this by giving a new DE 4S or a written notice to
the payer of your sick pay.
(a) Under a plan your employer takes part in.
(b) In place of wages for any period when
you are temporarily absent from work
because of sickness or injury.
DE 4S Rev. 1 (7-15) (INTERNET)
Page 1 of 1
CU
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