Form B-117 - Request For Change Of Income Tax Withholding Status

Vermont Department of Labor

REQUEST FOR CHANGE OF

INCOME TAX WITHHOLDING STATUS

ID # ____

I wish to request a change of my income tax withholding status. I understand that this change

is not retroactive, but will only affect claims filed after the date of this authorization.

I elect to have taxes withheld from my Unemployment Insurance check.

I understand a total of 10% of my gross weekly Unemployment amount will

be deducted for federal tax. In addition, I understand that 24% of my

federal withholding amount will be withheld for State of Vermont tax withholding.

I wish to stop deductions of federal and state tax from my weekly

Unemployment checks.

I understand that this change is final and must remain in effect for the remainder of my

existing benefit year.

Signature: _________________________________

Date: ____________________

RETURN TO:

Vermont Department of Labor

P.O. Box 189

Montpelier, VT 05601-0189

Fax the form to the department at

802-828-9191

B-117 (7/06)

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Parent category: Legal