Form M-4 - Massachusetts Employee'S Withholding Exemption Certificate

FORM

MASSACHUSETTS EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE

Rev. 1/12

M-4

Print full name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Social Security no. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Print home address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

City. . . . . . . . . . . . . . . . . . . . . . .

State . . . . . . . . . . . . . . . Zip . . . . . . . . . . . . . . . .

Employee:

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS

File this form or Form W-4 with

1. Your personal exemption. Write the figure “1.” If you are age 65 or over or will be before next year, write “2”

. . . . . . .

. . . . . . . .

your employer. Otherwise,

Massachusetts Income Taxes

2. If married and if exemption for spouse is allowed, write the figure “4.” If your spouse is age 65 or over or will

will be withheld from your

be before next year and if otherwise qualified, write “5.” See Instruction C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . .

wages without exemptions.

3. Write the number of your qualified dependents. See Instruction D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . .

Employer:

4. Add the number of exemptions which you have claimed above and write the total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Keep this certificate with your

records. If the employee is

5. Additional withholding per pay period under agreement with employer $ _____________________

believed to have claimed

excessive exemptions, the

A.

Check if you will file as head of household on your tax return.

Massachusetts Department

of Revenue should be so

B.

Check if you are blind.

C.

Check if spouse is blind and not subject to withholding.

advised.

D.

Check if you are a full-time student engaged in seasonal, part-time or temporary employment whose estimated annual income

will not exceed $8,000.

EMPLOYER: DO NOT withhold if Box D is checked.

I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.

Date. . . . . . . . . . . . . . . . . . . . . . . . . . . Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

THIS FORM MAY BE REPRODUCED

THE COMMONWEALTH OF MASSACHUSETTS, DEPARTMENT OF REVENUE

A. Number. If you claim more than the correct number of exemptions, civil

C. Spouse. If your spouse is not working or if she or he is working but not

and criminal penalties may be imposed. You may claim a smaller number of

claiming the personal exemption or the age 65 or over exemption, general-

exemptions. If you do not file a certificate, your employer must withhold on

ly you may claim those exemptions in line 2. However, if you are planning to

the basis of no exemptions.

file separate annual tax returns, you should not claim withholding exemp-

tions for your spouse or for any dependents that will not be claimed on your

If you expect to owe more income tax than will be withheld, you may either

annual tax return.

claim a smaller number of exemptions or enter into an agreement with your

employer to have additional amounts withheld.

If claiming a wife or husband, write “4” in line 2. Using “4” is the withholding

system adjustment for the $4,400 exemption for a spouse.

You should claim the total number of exemptions to which you are entitled to

prevent excessive overwithholding, unless you have a significant amount of

D. Dependent(s). You may claim an exemption in line 3 for each individual

other income.

who qualifies as a dependent under the Federal Income Tax Law. In addition,

if one or more of your dependents will be under age 12 at year end, add “1”

If you work for more than one employer at the same time, you must

to your dependents total for line 3.

not claim any exemptions with employers other than your principal

employer.

You are not allowed to claim “federal withholding deductions and

adjustments” under the Massachusetts withholding system.

If you are married and if your spouse is subject to withholding, each may

claim a personal exemption.

If you have income not subject to withholding, you are urged to have

additional amounts withheld to cover your tax liability on such income.

B. Changes. You may file a new certificate at any time if the number of

See line 5.

exemptions increases. You must file a new certificate within 10 days if the

number of exemptions previously claimed by you decreases. For example,

if during the year your dependent son’s income indicates that you will not

provide over half of his support for the year, you must file a new certificate.

IF THE ALLOWABLE MASSACHUSETTS WITHHOLDING EXEMPTIONS ARE THE SAME

AS YOU ARE CLAIMING FOR U.S. INCOME TAXES, COMPLETE U.S. FORM W-4 ONLY.