Form De 4s - Request For State Income Tax Withholding From Sick Pay
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1Request for State Income Tax
Withholding From Sick Pay
DE 4S
File this form with the payer of your sick pay.
Form
Type or print your full name
Your social security number
Home address (number and street or rural route)
City or town, state, and ZIP code
Claim or identification number (if any)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
I request income tax withholding from my sick-pay payments. I want the following amount to be withheld from each payment
. . . . . .
Employee’s signature
Date
Detach along this line. Give the top part of this form to the payer; keep the lower part for your records
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General Instructions
The Information Practices Act Notice. –
(b) in place of wages for any period when
Information collected on this is for administering
you are temporarily absent from work
the Personal Income Tax Law, Section 13028.6 of
because of sickness or injury.
the California Unemployment Insurance Code.
Amount to Be Withheld. – Enter on this form the
Purpose of Form. – To request State Income Tax
amount you want withheld from each payment.
withholding from sick pay. File this form ONLY if
You can use the worksheet accompanying Form
the sick pay is received from a third party, such as
DE 4 to estimate the amount of income tax you
an insurance company or trust. You do not have to
want withheld from each sick-pay payment.
file this form if you receive sick pay from your
employer as you have previously submitted a
Statement of Income Tax Withheld. – After the
withholding form.
end of the year, you will receive a Form W-2
reporting the taxable sick pay paid and income
You may not want to use Form DE 4S if you
tax withheld during the prior year. These
already have all your tax liability covered by
amounts may be included on your W-2 with your
estimated tax payments or other withholding.
other wages and withholding.
Definition. – Sick pay is a payment you receive:
Changing Your Withholding. – Form DE 4S
remains in effect until you change or cancel it.
(a) under a plan your employer takes part in,
You can do this by giving a new DE 4S or a
and
written notice to the payer of your sick pay.
DE 4S (7-05) (INTERNET)
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