Form Ct-W4 - Employee'S Withholding Certifi Cate

Department of Revenue Services

Form CT-W4

Effective January 1,

2013

State of Connecticut

Employee’s Withholding Certiﬁ cate

(Rev.

)

11/12

Complete this form in blue or black ink only.

Employee Instructions

• Read instructions on Page 2 before completing this form.

• Choose the statement that best describes your gross income.

• Enter the Withholding Code on Line 1 below.

• Select the ﬁ ling status you expect to report on your Connecticut

income tax return. See instructions.

Withholding

Filing Separately **

Filing Jointly *

Code

Our expected combined annual gross income is less than or

My expected annual gross income is less than or equal to

equal to $24,000 or I am claiming exemption under the Military

$12,000 or I am claiming exemption under the MSRRA ***

Spouses Residency Relief Act (MSRRA) *** and no withholding

and no withholding is necessary.

is necessary.

My expected annual gross income is greater than $12,000.

My spouse is employed and our expected combined annual

I have signiﬁ cant nonwage income and wish to avoid having

gross income is greater than $24,000 and less than or equal

too little tax withheld.

to $100,500. See Certain Married Individuals, Page 2.

I am a nonresident of Connecticut with substantial other income.

My spouse is not employed and our expected combined

Withholding

Single

annual gross income is greater than $24,000.

Code

My expected annual gross income is less than or equal to

My spouse is employed and our expected combined

annual gross income is greater than $100,500.

$14,000 and no withholding is necessary.

I have signiﬁ cant nonwage income and wish to avoid having

My expected annual gross income is greater than $14,000.

too little tax withheld.

I have signiﬁ cant nonwage income and wish to avoid having

too little tax withheld.

I am a nonresident of Connecticut with substantial other income.

Withholding

Qualifying Widow(er) With Dependent Child

Code

Withholding

Head of Household

My expected annual gross income is less than or equal to

Code

$24,000 or I am claiming exemption under the MSRRA ***

My expected annual gross income is less than or equal to

and no withholding is necessary.

$19,000 and no withholding is necessary.

My expected annual gross income is greater than

My expected annual gross income is greater than $19,000.

$24,000.

I have signiﬁ cant nonwage income and wish to avoid having

too little tax withheld.

I am a nonresident of Connecticut with substantial other income.

** Filing separately includes ﬁ ling separately for federal and

Connecticut and ﬁ ling separately for Connecticut only.

* Filing jointly includes ﬁ ling jointly for federal and Connecticut and

*** If you are claiming the Military Spouses Residency Relief Act

ﬁ ling jointly for Connecticut only.

(MSRRA) exemption, see instructions on Page 2.

Employees: See Employee General Instructions on Page 2.

Sign and return Form CT-W4 to your employer. Keep a copy for your records.



Check if you are claiming

1. Withholding Code: Enter Withholding Code letter chosen from above. ....................... 1.

the

MSRRA

exemption

and enter state of legal

2. Additional withholding amount per pay period: If any, see Page 3 instructions. . ......... 2. $

residence/domicile:

3. Reduced withholding amount per pay period: If any, see Page 3 instructions. ............ 3. $

_____________________

First name

Last name

Home address

Social Security Number

City/town

State

ZIP code

Declaration: I declare under penalty of law that I have examined this certiﬁ cate and, to the best of my knowledge and belief, it is true, complete,

and correct. I understand the penalty for reporting false information is a ﬁ ne of not more than $5,000, imprisonment for not more than ﬁ ve years,

or both.

Employee’s signature

Date

Employers: See

Employer Instructions on Page 2.



 No

 Yes  Enter date hired:

Is this a new or rehired employee?

mm/dd/yyyy

Employer’s business name

Employer’s business address

Federal Employer Identiﬁ cation Number

City/town

State

ZIP code

Contact person

Telephone number

(

)

Form Ct-W4 - Employee'S Withholding Certifi Cate - 2013

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