Form W-4mn - Minnesota Employee Withholding Allowance/exemption Certificate - 2015
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2015 Minnesota Employee Withholding Allowance/Exemption
Certifi cate
Employees
You must complete and provide your employer with Form W-4MN if you:
• claim fewer Minnesota withholding allowances than your federal allowances;
• claim more than 10 Minnesota withholding allowances;
• want additional Minnesota withholding deducted from your pay each pay period; or
• claim to be exempt from federal withholding or claim to be exempt from Minnesota withholding.
If you are claiming the same number of Minnesota allowances as federal and the number claimed is 10 or less, do not complete
this form.
Employee’s fi rst name and initial
Last name
Employee’s Social Security number
Marital status (check one box)
Permanent address
Single; Married, but legally separated; or
Spouse is a nonresident alien
City
State
ZIP code
Married
Married, but withhold at higher Single rate
Employees: Read instructions on back, complete Section 1 OR Section 2, sign and give the completed form to your employer.
(Do not complete both Section 1 and Section 2. Completing both sections will make the form invalid.)
Section 1 — Determining Minnesota allowances
Complete Section 1 if you claim fewer Minnesota allowances than your federal allowances, AND/OR if you want additional Min-
nesota withholding deducted each pay period.
1 Total number of federal allowances claimed on federal Form W-4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Total number of Minnesota allowances (line 2 cannot be more than line 1) . . . . . . . . . . . . . . . . . . . . . . . 2
3 Additional Minnesota withholding you want deducted each pay period . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 $
Section 2 — Exemption from Minnesota withholding
Complete Section 2 if you claim to be exempt from Minnesota income tax withholding (see Section 2 instructions for qualifi ca-
tions). If applicable, check one box below to indicate the reason why you believe you are exempt:
I meet the requirements and claim exempt from both federal and Minnesota income tax withholding.
Even though I did not claim exempt from federal withholding, I claim exempt from Minnesota withholding because I had no
Minnesota income tax liability last year, I received a refund of all Minnesota income tax withheld, AND I expect to have no Min-
nesota income tax liability this year.
My spouse is a military service member assigned to a military location in Minnesota, my domicile (legal residence) is in another
state, AND I am in Minnesota solely to be with my spouse. My state of domicile is
.
I am an American Indian living and working on a reservation.
I certify that all information provided in Section 1 OR Section 2 is correct. I understand there is a $500 penalty for fi ling
a false withholding allowance/exemption certifi cate.
Employee’s signature
Date
Daytime phone
Employees: Give the completed form to your employer.
Employers
If you are required to send a copy of this form to the Department of Revenue (see instructions), you must enter the employer
information below and mail this form to: Minnesota Revenue, Mail Station 6501, St. Paul, MN 55146-6501. (Incomplete forms
are considered invalid.) A $50 penalty may be assessed for each required Form W-4MN not fi led with the department.
Keep a copy for your records.
Name of employer
Federal employer ID number (FEIN)
Minnesota tax ID number
Address
City
State
ZIP code
Questions? Website: Email: withholding.tax@state.mn.us.
Phone: 651-282-9999 or 1-800-657-3594.
(Rev. 11/14)
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