Personal Withholding Exemption Variance Certificate Form - Maine Revenue Services
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1STATE OF MAINE
MAINE REVENUE SERVICES
24 STATE HOUSE STATION
AUGUSTA, MAINE
04333-0024
ANGUS S. KING, JR.
ELAINE L. CORROW
GOVERNOR
ACTING EXECUTIVE DIRECTOR
INCOME/ESTATE TAX DIVISION
PERSONAL WITHHOLDING EXEMPTION VARIANCE CERTIFICATE
Complete this form if you want to claim more personal allowances for Maine withholding purposes than for
federal withholding. Send this form with all three copies attached to the address above.
FIRST NAME
MIDDLE INITIAL
LAST NAME
SOCIAL SECURITY NO.
ADDRESS
CITY
STATE
ZIP CODE
(
)
Home Telephone Number
Filing Status (married joint, single, etc.)
Number of exemptions you claimed on your last federal return
Number of personal allowances you currently claim less the allowances claimed for the
child tax credit for federal withholding (Form W-4)
Number of personal allowances you currently claim for Maine withholding (Form W-4ME)
I request the following status for Maine withholding for tax year __________ :
Marital Status
Number of Personal Allowances
Reason for change
REQUEST APPROVED
REQUEST REJECTED
Reason (if request is rejected)
OFFICIAL SIGNATURE
DATE
NOTE: This certificate is valid for only the year in which it is issued. A certificate must be submitted for each year a
claim is made. Employee should provide completed form with all copies attached to Maine Revenue Services for
approval. Once reviewed, the white original and yellow copy of the certificate will be mailed to the employee.
Phone: (207) 626-8475
(207)287-4477 (TTY)
Fax: (207) 287-4028
e-mail: maine.revenue@state.me.us
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