Personal Withholding Allowance Variance Certificate Form
ADVERTISEMENT
1STATE OF MAINE
MAINE REVENUE SERVICES
INCOME/ESTATE TAX DIVISION
P.O. BOX 1060
AUGUSTA, MAINE 04332-1060
PERSONAL WITHHOLDING ALLOWANCE VARIANCE CERTIFICATE
Complete all sections of this form if you want to claim more personal allowances for Maine
withholding purposes than for federal withholding on Form W-4ME. Once complete, send
this form to Maine Revenue Services at the address above.
FIRST NAME
MIDDLE INITIAL
LAST NAME
SOCIAL SECURITY NO.
ADDRESS
CITY
STATE
ZIP CODE
Home Telephone Number ( ____ ) _________ - ___________________
Filing Status claimed on your last federal return (single, married fi ling jointly, married
fi ling separately, head of household or qualifying widow(er))
__________________
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 fi ling 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 certifi cate is valid for only the year in which it is issued. A certifi cate must be submitted for each year a claim
is made. The employee should provide the completed form to Maine Revenue Services for approval. Once reviewed, two
copies of the certifi cate will be mailed to the employee: one for the employer; one for the employee’s records.
Phone: (207) 626-8475
TTY: 711
Fax: (207) 624-9694
Email: withholding.tax@maine.gov
Rev: 05/16
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial