Form W-4s - Request For Federal Income Tax Withholding From Sick Pay - 2017
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2W-4S
Request for Federal Income Tax
OMB No. 1545-0074
Form
Withholding From Sick Pay
2017
Give this form to the third-party payer of your sick pay.
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Department of the Treasury
Information about Form W-4S is available at
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Internal Revenue Service
Type or print your first name and middle initial.
Last 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)
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I request federal income tax withholding from my sick pay payments. I want the following amount to be withheld from
$
each payment. (See Worksheet below.)
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Employee’s signature
Date
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Separate here and give the top part of this form to the payer. Keep the lower part for your records.
Worksheet (Keep for your records. Do not send to the Internal Revenue Service.)
1 Enter amount of adjusted gross income that you expect in 2017 .
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2 If you plan to itemize deductions on Schedule A (Form 1040), enter the estimated total of your deductions. For
2017, you may have to reduce your itemized deductions if your income is over $313,800 and you’re married
filing jointly or you’re a qualifying widow(er); $287,650 if you’re head of household; $261,500 if you’re single, not
head of household and not a qualifying widow(er); or $156,900 if you’re married filing separately. See Pub. 505
for details. If you don’t plan to itemize deductions, enter the standard deduction. (See the instructions on page 2
for the standard deduction amount, including additional amounts for age and blindness.)
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3 Subtract line 2 from line 1 .
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4 Exemptions. Multiply $4,050 by the number of personal exemptions
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5 Subtract line 4 from line 3 .
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6 Tax. Figure your tax on line 5 by using the 2017 Tax Rate Schedule X, Y, or Z on page 2. Don’t use the Tax Table
or Tax Rate Schedule X, Y, or Z in the 2016 Form 1040, 1040A, or 1040EZ instructions .
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7 Credits (child tax and higher education credits, credit for child and dependent care expenses, etc.)
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8 Subtract line 7 from line 6 .
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9 Estimated federal income tax withheld or to be withheld from other sources (including amounts withheld due to a
prior Form W-4S) during 2017 or paid or to be paid with 2017 estimated tax payments .
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10 Subtract line 9 from line 8 .
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11 Enter the number of sick pay payments you expect to receive this year to which this Form W-4S will apply
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12 Divide line 10 by line 11. Round to the nearest dollar. This is the amount that should be withheld from each sick
pay payment. Be sure it meets the requirements for the amount that should be withheld, as explained under
Amount to be withheld below. If it does, enter this amount on Form W-4S above .
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General Instructions
• Must not reduce the net amount of each sick pay payment that you
receive to less than $10.
Purpose of form. Give this form to the third-party payer of your sick
For payments larger or smaller than a regular full payment of sick pay,
pay, such as an insurance company, if you want federal income tax
the amount withheld will be in the same proportion as your regular
withheld from the payments. You aren’t required to have federal income
withholding from sick pay. For example, if your regular full payment of
tax withheld from sick pay paid by a third party. However, if you choose
$100 a week normally has $25 (25%) withheld, then $20 (25%) will be
to request such withholding, Internal Revenue Code sections 3402(o)
withheld from a partial payment of $80.
and 6109 and their regulations require you to provide the information
Caution: You may be subject to a penalty if your tax payments during
requested on this form. Don’t use this form if your employer (or its
the year aren’t at least 90% of the tax shown on your tax return. For
agent) makes the payments because employers are already required to
exceptions and details, see Pub. 505, Tax Withholding and Estimated
withhold federal income tax from sick pay.
Tax. You may pay tax during the year through withholding or estimated
Note: If you receive sick pay under a collective bargaining agreement,
tax payments or both. To avoid a penalty, make sure that you have
see your union representative or employer.
enough tax withheld or make estimated tax payments using Form
Definition. Sick pay is a payment that you receive:
1040-ES, Estimated Tax for Individuals. You may estimate your federal
income tax liability by using the worksheet above.
• Under a plan to which your employer is a party, and
Sign this form. Form W-4S is not valid unless you sign it.
• In place of wages for any period when you’re temporarily absent from
work because of your sickness or injury.
Statement of income tax withheld. After the end of the year, you’ll
receive a Form W-2, Wage and Tax Statement, reporting the taxable
Amount to be withheld. Enter on this form the amount that you want
sick pay paid and federal income tax withheld during the year. These
withheld from each payment. The amount that you enter:
amounts are reported to the Internal Revenue Service.
• Must be in whole dollars (for example, $35, not $34.50).
(continued on back)
• Must be at least $4 per day, $20 per week, or $88 per month based on
your payroll period.
W-4S
For Paperwork Reduction Act Notice, see page 2.
Form
(2017)
Cat. No. 10226E
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