Form M-4p - Massachusetts Withholding Exemption Certificate For Pension, Annuity And Other Periodic And Nonperiodic Payments

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FORM

MASSACHUSETTS WITHHOLDING EXEMPTION CERTIFICATE

Rev. 1/08

M-4P

FOR PENSION, ANNUITY AND OTHER PERIODIC AND NONPERIODIC PAYMENTS

Print full name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Social Security no. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Print home address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

City. . . . . . . . . . . . . . . . . . . . . . .

State . . . . . . . . . . . . . . . Zip . . . . . . . . . . . . . . . .

Send this form to

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS

the payer of your

1. Your personal exemption. Write the figure “1.” If you are age 65 or over or will be before next year, write “2”

. . . . . . . . .

. . . . . . . .

pension or other

2. If married and if exemption for spouse is allowed, write the figure “4.” If your spouse is age 65 or over or will

subject payment.

be before next year and if otherwise qualified, write “5.” See Instruction C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . .

3. Write the number of your qualified dependents. See Instruction D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . .

4. Add the number of exemptions which you have claimed above and write the total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Additional withholding per pay period under agreement with employer $ ______________________

Check if you will file as head of household on your tax return.

Check if you are blind.

Check if spouse is blind and not subject to withholding.

Check if you are exempt from Massachusetts income tax withholding because your legal residence (domicile) is elsewhere and

your pension is from certain pension plans (see instruction E).

I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.

Date. . . . . . . . . . . . . . . . . . . . . . . . . . . Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

THIS FORM MAY BE REPRODUCED

THE COMMONWEALTH OF MASSACHUSETTS • DEPARTMENT OF REVENUE

The Massachusetts income tax withholding provisions apply to pension, an-

C. Spouse. If your spouse is not working or if she or he is working but not

nuity and other periodic and nonperiodic payments made to those who have

claiming the personal exemption or the age 65 or over exemption, generally

not elected to be exempt from the U.S. income tax withholding provisions.

you may claim those exemptions in line 2. However, if you are planning to file

separate annual tax returns, you should not claim withholding exemptions

A. Number. If you claim more than the correct number of exemptions, civil

for your spouse or for any dependents that will not be claimed on your annual

and criminal penalties may be imposed. You may claim a smaller number of

tax return.

exemptions. If you do not file a certificate, Massachusetts withholding will be

based on “0” exemptions.

If claiming a wife or husband, write “4” in line 2. Using “4” is the withholding

system adjustment for the $4,400 exemption for a spouse.

If you expect to owe more income tax than will be withheld, you may either

claim a smaller number of exemptions or enter into an agreement with your

D. Dependent(s). You may claim an exemption in line 3 for each individual

payer to have additional amounts withheld.

who qualifies as a dependent under the Federal Income Tax Law. In addition,

if one or more of your dependents will be under age 12 at year end, add “1” to

You should claim the total number of exemptions to which you are entitled to

your dependents total for line 3.

prevent excessive overwithholding — unless you have a significant amount of

other income.

E. Payments not subject to tax Under Title 4 of the United States Code, sec-

tion 114, payments to nonresidents of Massachusetts from certain pension

If you or your spouse are claiming exemptions under Massachusetts

plans are not subject to tax.

withholding from other income (such as employment), do not claim the

If you elect not to have U.S. income tax withholding apply to pensions, other

same exemptions from this income.

periodic and nonperiodic payments in the future, Massachusetts law provides

B. Changes. You may file a new certificate at any time if the number of ex-

that Massachusetts withholding will cease on such payments.

emptions increases. You must file a new certificate within 10 days if the num-

ber of exemptions previously claimed by you decreases. For example, if

If you have income not subject to withholding, you are urged to have

during the year your dependent son’s income indicates that you will not pro-

additional amounts withheld to cover your tax liability on such income.

vide over half of his support for the year, you must file a new certificate.

See line 5.

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