Form M-4p - Massachusetts Withholding Exemption Certificate For Pension, Annuity And Other Periodic And Nonperiodic Payments

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FORM

MASSACHUSETTS WITHHOLDING EXEMPTION CERTIFICATE

Rev. 7/98

M-4P

FOR PENSION, ANNUITY AND OTHER PERIODIC AND NONPERIODIC PAYMENTS

Print full name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Social Security No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Print home address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

City. . . . . . . . . . . . . . . . . . . . . . . .

State . . . . . . . . . . . . . . . . Zip Code . . . . . . . . . .

Send this form to

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS

the payer of your

1. Your personal exemption. Write the figure “1”. If you are age 65 or over or will be before next year, write “2”.

. . . . . .

. . . . . . . .

pension or other

2. IF MARRIED and if exemption for spouse is allowed, write the figure “4”. If your spouse is age 65 or over or will

subject payment.

be before next year and if otherwise qualified, write “5”. See Instruction C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . .

3. Write the number of your qualified dependents. See Instruction D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . .

4. Add the number of exemptions which you have claimed above and write the total........ ................ ...............

5. Additional withholding per pay period under agreement with employer $ _____________________

Check if you will file as head of household on your tax return.

Check if you are blind.

Check if spouse is blind and not subject to withholding.

Check if you are exempt from Massachusetts income tax withholding because your legal residence

(domicile) is elsewhere and your pension is from certain pension plans (see instruction E).

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

The Massachusetts income tax withholding provisions apply to pen-

C. SPOUSE — If your spouse is not working or if she or he is working but

sion, annuity and other periodic and nonperiodic payments made to those

not claiming the personal exemption or the age 65 or over exemption,

who have not elected to be exempt from the U.S. income tax withholding

generally you may claim those exemptions in line 2. However, if you are

provisions.

planning to file separate annual tax returns, you should not claim with-

holding exemptions for your spouse or for any dependents that will not be

A. NUMBER — If you claim MORE than the correct number of exemp-

claimed on your annual tax return.

tions, civil and criminal penalties may be imposed. You may claim a

If claiming a wife or husband, write “4” in line 2. Using “4” is the

smaller number of exemptions. If you do not file a certificate,

withholding system adjustment for the $4,400 exemption for a spouse.

Massachusetts withholding will be based on “0” exemptions.

D. DEPENDENT(S) — You may claim an exemption in line 3 for each

If you expect to owe more income tax than will be withheld, you may ei-

individual who qualifies as a dependent under the Federal Income Tax

ther claim a smaller number of exemptions or enter into an agreement

Law. In addition, if one or more of your dependents will be under age 12 at

with your payer to have additional amounts withheld.

year end, add “1” to your dependents total for line 3.

You should claim the total number of exemptions to which you are enti-

E. PAYMENTS NOT SUBJECT TO TAX — Under Title 4 of the United

tled to prevent excessive overwithholding — unless you have a significant

States Code, section 114, payments to nonresidents of Massachusetts

amount of other income.

from certain pension plans are not subject to tax.

IF YOU OR YOUR SPOUSE ARE CLAIMING EXEMPTIONS UNDER

If you elect not to have U.S. income tax withholding apply to pensions,

MASSACHUSETTS WITHHOLDING FROM OTHER INCOME (SUCH

other periodic and nonperiodic payments in the future, Massachusetts law

AS EMPLOYMENT), DO NOT CLAIM THE SAME EXEMPTIONS FROM

provides that Massachusetts withholding will cease on such payments.

THIS INCOME.

IF YOU HAVE INCOME NOT SUBJECT TO WITHHOLDING, YOU

B. CHANGES — You may file a new certificate at any time if the number

ARE URGED TO HAVE ADDITIONAL AMOUNTS WITHHELD TO

of exemptions INCREASES. You MUST file a new certificate within 10 days

COVER YOUR TAX LIABILITY ON SUCH INCOME. SEE LINE 5.

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

12M 5/98 GC98C41

new certificate.

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