Form 89-350-12-8-1-000 - Mississippi Employee'S Withholding Exemption Certificate printable pdf download

Form 89-350-12-8-1-000 (Rev. 11/12)

MISSISSIPPI EMPLOYEE'S WITHHOLDING EXEMPTION CERTIFICATE

Employee's Name

SSN

Employee's Residence

Address

Mississippi Department of Revenue

P.O. Box 960

Zip Code

Number and Street

City or Town

State

Jackson, MS

39205

CLAIM YOUR WITHHOLDING PERSONAL EXEMPTION

Personal Exemption Allowed

Amount Claimed

Marital Status

Enter $6,000 as exemption . . . . 

1. Single

EMPLOYEE:

File this form with your

(a)



Spouse NOT employed: Enter $12,000

employer.

Otherwise, you

2. Marital Status

must withhold Mississippi

Spouse IS employed: Enter that part of

(Check One)

income tax from the full

(b)

$12,000 claimed by you in multiples of

amount of your wages.

$500.

See instructions 2(b) below

.

Enter $9,500 as exemption.

To qualify

as head of family, you must be single

and have a dependent living in the

3. Head of Family

home with you.

See instructions 2(c)

and 2(d)below . . . . . . . . . . . .

EMPLOYER:

You may claim $1,500 for each dependent*, other than

for taxpayer and spouse, who receives chief support

Keep this certificate with

from you and who qualifies as a dependent for Federal

your records.

If the

4. Dependents

income tax purposes.

employee is believed to

* A head of family may claim $1,500 for each

have claimed excess

Number Claimed

dependents excluding the one which qualifies you

exemption, the Department

as head of family. Multiply number of dependents



of Revenue should be

claimed by you by $1,500. Enter amount claimed . . .

advised.

● Age 65 or older

Husband

Wife

Single

5. Age and

● Blind

Husband

Wife

Single

Blindness

Multiply the number of blocks checked by $1,500.

Enter the amount claimed

. . . . .

Note:

No exemption allowed for age or blindness

for dependents.

6. TOTAL AMOUNT OF EXEMPTION CLAIMED - Lines 1 through 5...

7. Additional dollar amount of withholding per pay period if

agreed to by your employer . . . . . .

. . . . . . . . . . .

Military Spouses

8. If you meet the conditions set forth under the Service Member

Residencey Relief Act

Civil Relief, as amended by the Military Spouses Residency

Exemption from Mississippi

Relief Act, and have no Mississippi tax liability, write

"Exempt" on Line 8.

You must attach a copy of the Federal

Withholding

Form DD-2058 and a copy of your Military Spouse ID Card to

this form so your employer can validate the exemption claim..

I declare under the penalties imposed for filing false reports that the amount of exemption claimed on this

certificate does not exceed the amount to which I am entitled or I am entitled to claim exempt status.

Employee's Signature:

Date:

INSTRUCTIONS

1. The personal exemptions allowed:

should not include themselves or their spouse. Married taxpayers may divide the number of their

dependents between them in any manner they choose; for example, a married couple has 3 children

(a) Single Individuals

$6,000

(d) Dependents

$1,500

who qualify as dependents. The taxpayer may claim 2 dependents and the spouse 1; or the taxpayer

(b) Married Individuals (Jointly)

$12,000

(e) Age 65 and Over

$1,500

may claim 3 dependents and the spouse none. Enter the amount of dependent exemption on Line 4.

$9,500

(f) Blindness

$1,500

2. Claiming personal exemptions:

(e) An additional exemption of $1,500 may be claimed by either taxpayer or spouse or both if

either or both have reached the age of 65 before the close of the taxable year. No

(a) Single Individuals enter $6,000 on Line 1.

additional exemption is authorized for dependents by reason of age. Check applicable

blocks on Line 5.

(b) Married individuals are allowed a joint exemption of $12,000.

(f) An additional exemption of $1,500 may be claimed by either taxpayer or spouse or both if

If the spouse is not employed, enter $12,000 on Line 2(a). If the spouse is employed, the

either or both are blind. No additional exemption is authorized for dependents by reason of

exemption of $12,000 may be divided between taxpayer and spouse in any manner they

blindness. Check applicable blocks on Line 5. Multiply number of blocks checked on Line 5

choose - in multiples of $500. For example, the taxpayer may claim $6,500 and the spouse

by $1,500 and enter amount of exemption claimed.

claims $5,500; or the taxpayer may claim $8,000 and the spouse claims $4,000. The total

claimed by the taxpayer and spouse may not exceed $12,000. Enter amount claimed by

3. Total Exemption Claimed:

you on Line 2(b).

Add the amount of exemptions claimed in each category and enter the total on Line 6. This

amount will be used as a basis for withholding income tax under the appropriate withholding

tables.

A head of family is a single individual who maintains a home which is the principal place of

4. A NEW EXEMPTION CERTIFICATE MUST BE FILED WITH YOUR EMPLOYER WITHIN

abode for himself and at least one other dependent. Single individuals qualifying as a head

30 DAYS AFTER ANY CHANGE IN YOUR EXEMPTION STATUS.

of family enter $9,500 on Line 3. If the taxpayer has more than one dependent, additional

exemptions are applicable. See item (d).

5. PENALTIES ARE IMPOSED FOR WILLFULLY SUPPLYING FALSE INFORMATION

(d) An additional exemption of $1,500 may generally be claimed for each dependent of the

6. IF THE EMPLOYEE FAILS TO FILE AN EXEMPTION CERTIFICATE WITH HIS

taxpayer. A dependent is any relative who receives chief support from the taxpayer and

EMPLOYER, INCOME TAX MUST BE WITHHELD BY THE EMPLOYER ON TOTAL

who qualifies as a dependent for Federal income tax purposes. Head of family individuals

p p

may claim an additional exemption for each dependent excluding the one which is required

WAGES WITHOUT THE BENEFIT OF EXEMPTION..

for head of family status. For example, a head of family taxpayer has 2 dependent children

. To comply with the Military Spouse Residency Relief Act (PL111-97) signed on November

and his dependent mother living with him. The taxpayer may claim 2 additional exemptions.

11, 2009.

Married or single individuals may claim an additional exemption for each dependent, but

Form 89-350-12-8-1-000 - Mississippi Employee'S Withholding Exemption Certificate

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