Form W-4v - Voluntary Withholding Certificate From Unemployment Compensation - 2004

taken. This amount is taxable income to you. For more information, see the instructions for your Federal Income

Tax Return. Form 1099G will also list the amount of Federal and/or State income taxes withheld. You are not

required to file a copy of this form with either your annual Federal or State Income Tax forms. To avoid delay of

receipt of your 1099G, be sure to notify this agency of all change of addresses during the calendar year. The U.S.

Postal Service will not forward Department of Labor mail.

If you repay monies on an overpayment during any calendar year, the repayment amount will be reflected on the

1099G issued to you. It is a good idea to keep all receipts sent to you as verification of repayments of an

overpayment. U.S. Individual Income Tax Return Forms 1040, 1040A, and 1040-EZ instruct you as to how to

report unemployment compensation received and repayments made during 2003.

6. What Happens If I Want Part Or All Of The Amount Withheld Returned To Me?

Taxes withheld from your unemployment check are forwarded to the Internal Revenue Service (Federal) and/or the

Maine Revenue Service (State). Therefore, taxes withheld are not refundable.

IF YOU CHOOSE TO NOT HAVE TAXES WITHHELD, DO NOT RETURN THE

ATTACHED FORM W-4V.

MAIL THIS FORM TO:

Maine Department of Labor

Bureau of Unemployment Compensation

Benefit Division

P.O. Box 259

Augusta, Maine 04332-0259

If you want income taxes withheld or stopped, cut here and mail this form to the State Bureau of Unemployment Compensation address on the form.

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W-4V

|Voluntary Withholding Certificate From

|

Form

|

Unemployment Compensation

|

2004

Department of the Treasury

Internal Revenue Service

____________________________________________________________________________________________

Type or print your full name

|Social Security Number

____________________________________________________________________ |

Home mailing address (number and street or rural route)

|

____________________________________________________________________ |_______________________

City or town, state and ZIP Code

____________________________________________________________________________________________

Complete one or both of the following if you want to begin having income taxes withheld from your unemployment

checks or want to stop this (these) deduction(s):

YES

NO

1. I want FEDERAL income tax withheld from my weekly unemployment benefits (fixed rate of 10%) [ ]

[ ]

2. I want STATE income tax withheld from my weekly unemployment benefits (fixed rate of 5%)

[ ]

[ ]

I understand that my withholding status can only be changed (start or stop) upon receipt of this form.

____________________________________________________________________________________________

Your Signature

Date

____________________________________________________________________________________________

Me. I-5 Web (rev. 01/04)

Must Be Completed With Signature To Be Valid