Form Ct-W4 - Employee'S Withholding Certificate
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1Department of Revenue Services
Form CT-W4
Effective January 1, 2009
State of Connecticut
Employee’s Withholding Certifi cate
(Rev. 11/08)
Complete this form in blue or black ink only. Complete this form so your employer can withhold the correct amount of Connecticut income tax from
your wages. See Employee Instructions, Page 2.
Step 1 - Determine your Withholding Code:
Select the fi ling status you expect to report on your Connecticut income tax return. Generally,
this will be the same fi ling status as your federal income tax return. However, see instructions for applicable exceptions. Choose the statement that
best describes your gross income, (see Gross Income, Page 2) and enter the Withholding Code in Step 2, Line 1. See Armed Forces Personnel
and Veterans; or Certain Married or Civil Union Individuals, Page 2.
Withholding
Withholding
Filing Separately **
Filing Jointly *
Code
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.
E
$12,000 and no withholding is necessary.
E
Our expected combined annual gross income is greater
My expected annual gross income is greater than $12,000.
A
than $24,000 and less than or equal to $100,500. See Special
I have signifi cant nonwage income and wish to avoid having
Rules for Certain Married or Civil Union Individuals, Page 2.
A
too little tax withheld.
D
My spouse is not employed and our expected combined
I am a nonresident of Connecticut with substantial other income.
D
annual gross income is greater than $24,000.
C
Withholding
Single
My spouse is employed and our expected combined
Code
annual gross income is greater than $100,500.
D
My expected annual gross income is less than or equal to
$13,500 and no withholding is necessary.
E
I have signifi cant nonwage income and wish to avoid having
too little tax withheld.
D
My expected annual gross income is greater than $13,500.
F
I am a nonresident of Connecticut with substantial other income.
D
I have signifi cant nonwage income and wish to avoid having
too little tax withheld.
D
Withholding
Qualifying Widow(er) With Dependent Child
Code
I am a nonresident of Connecticut with substantial other income.
D
My expected combined annual gross income is less than or
Withholding
Head of Household
equal to $24,000 and no withholding is necessary.
E
Code
My expected annual gross income is less than or equal to
My expected combined annual gross income is greater
$19,000 and no withholding is necessary.
E
than $24,000 and less than or equal to $100,500.
A
My expected annual gross income is greater than $19,000.
B
I have signifi cant nonwage income and wish to avoid having
too little tax withheld.
D
I have signifi cant nonwage income and wish to avoid having
too little tax withheld.
D
I am a nonresident of Connecticut with substantial other income.
D
I am a nonresident of Connecticut with substantial other income.
D
* Filing Jointly includes fi ling jointly for federal and Connecticut and
fi ling jointly for Connecticut only
** Filing separately includes fi ling separately for federal and Connecticut and fi ling separately for Connecticut only
Step 2 - Complete Lines 1 through 11:
Sign, make a copy for yourself, and return the original to your employer.
RESET FORM
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
Ml
Last name
5. Home address
6. Social Security Number
7. City/town
8. State
9. 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, or imprisonment for not more than fi ve years, or both.
10. Employee’s signature
11. Date
X
M
M
D
D
Y
Y
Employers Must Complete Items 12 through 20.
12. Is this a new or rehired employee?
No
Yes
(Enter the date of hire at right.)
M
M
D
D
Y
Y
13. Employer’s business name
14. Employer’s business address
15. Federal Employer Identifi cation Number
16. City/town
17. State
18. ZIP code
19. Contact person
20. Telephone number
Employer Instructions on Reverse
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