Form Ct-W4 - Employee'S Withholding Certificate

Form CT-W4

Department of Revenue Services

Effective July 1, 2003

Employee’s Withholding Certificate

State of Connecticut

Complete this form so your employer can withhold the correct amount of Connecticut income tax from your wages.

Instructions:

• Go to the chart below that describes the filing status you expect to report on your federal income tax return. (Armed Forces Personnel and

Veterans, see Special Instructions for Armed Forces Personnel and Veterans , Page 2)

• Choose the statement that best describes your income. (Gross income means income from all sources.) Enter the Withholding Code in Step 2, Line 1.

• Complete Step 2. Sign, make a copy for yourself, and return the original to your employer.

• For more information, see Employee Instructions on Page 2.

Step 1 - Determine your Withholding Code.

Withholding

Married Filing Jointly

Single

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 and no withholding is necessary

$12,500 and no withholding is necessary

Our expected combined annual gross income is greater

My expected annual gross income is greater than $12,500

than $24,000 and less than or equal to $100,500 (See Special

I have significant nonwage income and wish to avoid having

Rules for Certain Married Individuals , Page 2)

too little tax withheld

My spouse is not employed and our expected combined

I am a nonresident of Connecticut with substantial other income

annual gross income is greater than $24,000

My spouse is employed and our expected combined annual

Withholding

Head of Household

gross income is greater than $100,500

Code

I have significant nonwage income and wish to avoid having

My expected annual gross income is less than or equal to

too little tax withheld

$19,000 and no withholding is necessary

I am a nonresident of Connecticut with substantial other income

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

I have significant nonwage income and wish to avoid having

Withholding

Married Filing Separately

too little tax withheld

Code

I am a nonresident of Connecticut with substantial other income

My expected annual gross income is less than or equal to

$12,000 and no withholding is necessary

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

I have significant nonwage income and wish to avoid having

too little tax withheld

I am a nonresident of Connecticut with substantial other income

Please Print Clearly

Step 2 - Complete Lines 1 through 11.

1. Withholding Code (Enter Withholding Code letter chosen from Step 1 above): ............................ 1.

.00

2. Additional withholding amount per pay period, if any (See instructions on Page 3): ................ 2.

.00

3. Reduced withholding amount per pay period, if any (See instructions on Page 3): .................. 3.

4. First Name

Last Name

5. Home Address

6. Your Social Security Number

7. City/Town

8. State

9. Zip Code

I declare under penalty of law that I have examined this certificate and, to the best of my knowledge and belief, it is true, complete, and correct. I

understand that the penalty for reporting false information is a fine of not more than $5,000, or imprisonment for not more than five years, or both.

10. Employee’s Signature

11. Date

Employers Must Complete Items 12 through 21. Please print clearly.

. Is this a new or rehired employee?

Yes

If yes, provide the date of hire

13. Employer’s Business Name

14. Connecticut Tax Registration Number

15. Employer’s Business Address

16. Federal Employer Identification Number

17. City/Town

18. State

19. Zip Code

20. Contact Person

21. Telephone Number

Employer Instructions On Reverse

(Rev. 7/03)

Form Ct-W4 - Employee'S Withholding Certificate - 2003

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