CT-W4 Employee’s Withholding Certificate

Department of Revenue Services State of Connecticut (Rev. 12/19)
Form CT-W4 Employee’s Withholding Certificate
Effective January 1, 2020
Employee Instructions:
- Read the instructions on Page 2 before completing this form. You can view them by scrolling to the bottom and clicking on the preview PDF form. You will need to refer to the instruction form for the appropriate codes to enter below.
- Select the filing status you expect to report on your Connecticut income tax return. See instructions.
- Choose the statement that best describes your gross income.
- Enter the Withholding Code on Line 1 below.
1. Withholding Code: Enter Withholding Code letter chosen from page 1 of Form CT-W4.*
2. Additional withholding amount per pay period, if any, see instructions.
3. Reduced withholding amount per pay period, if any, see instructions.
Military Spouses Residency Relief Act (MSRRA)
If you are claiming an exemption from Connecticut income tax under the MSRRA, you must provide your employer with a copy of your military spouse’s Leave and Earnings Statement (LES) and a copy of your military dependent ID card.See Informational Publication 2019(5), Connecticut Income Tax Information for Armed Forces Personnel and Veterans.
Are you claiming the MSRRA exemption?

Check if you are claiming the MSRRA exemption and enter state of legal residence/domicile:
Enter State of Legal Residence
Full Name*
Social Security Number*
Home address (number and street, apartment number, suite number, PO Box)*
City, State, Zip*
Declaration: I declare under penalty of law that I have examined this certificate and, to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for reporting false information is a fine of not more than $5,000, imprisonment for not more than five years, or both.
Signature*

Clear
Date*

MonthDayYear
Date
Visit the DRS website at portal.ct.gov/DRS to download and print Connecticut tax forms and publications.
Should be Empty:

Form CT-W4 Employee’s Withholding Certificate

Effective January 1, 2020

Military Spouses Residency Relief Act (MSRRA)