Personal Withholding Allowance Variance Certificate - Maine Revenue Services

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STATE OF MAINE
MAINE REVENUE SERVICES
INCOME/ESTATE TAX DIVISION
P.O. BOX 1060
AUGUSTA, MAINE 04332-1060
PERSONAL WITHHOLDING ALLOWANCE VARIANCE CERTIFICATE
Complete this form if you want to claim more personal allowances for Maine withholding purposes than for
federal withholding. Send this form 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 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. Employee should provide completed form to Maine Revenue Services for approval. Once reviewed, two copies
of the certifi cate will be mailed to the employee.
Phone: (207) 626-8475
TTY: (888) 577-6690
Fax: (207) 624-9694
Email: withholding.tax@maine.gov
Rev: 07/11

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