Mississippi Withholding Certificate

Form 89-350-15-8-1-000 (Rev. 05/15)
MISSISSIPPI EMPLOYEE'S WITHHOLDING EXEMPTION CERTIFICATE
Employee's Name*
SSN*
Number and Street*
City or Town*
State*
Zip Code*
Personal Exemptions Allowed

1. Single
Single: Enter $6,000 as exemption
2. Marital Status
Spouse NOT employed: Enter $12,000
Spouse IS employed: Enter that part of $12,000 claimed by you in multiples of $500.
3. Head of Household
Head of Household: Enter $9,500 as exemption. To qualify as head of family, you must be single and have a dependent living in the home with you.
4. Dependents
purposes. You may claim $1,500 for each dependent, other than for taxpayer and spouse, who receives chief support from you and who qualifies as a dependent for Federal income tax purposes. A head of family may claim $1,500 for each dependent excluding the one which qualifies you as head of family. Enter the number of dependents claimed here.
The amount claimed for qualifying dependents by multiplying the number of dependents by $1,500
5. Age & Blindness
HusbandWifeSingle
HusbandWifeSingle
Count the number of boxes checked above for Age of 65 or older and Blindness. Enter the total here.
The amount claimed by multiplying the number of blocks checked above by $1500.00. No exemption allowed for age or blindness for dependents.
TOTAL AMOUNT OF EXEMPTIONS CLAIMED - Lines 1 through 5
7. Additional dollar amount of withholding per pay period if agreed to by your employer
Enter Additional Withholding Amount (optional)
8. If you meet the conditions set forth under the Service Member Civil Relief, as amended by the Military Spouses Residency Relief Act, and have no Mississippi tax liability, write "Exempt" on Line 8. You must attach a copy of the Federal Form DD-2058 and a copy of your Military Spouse ID Card to this form so your employer can validate the exemption claim.
Enter EXEMPT if you qualify
I declare under the penalties imposed for filing false reports that the amount of exemption claimed on this certificate does not exceed the amount to which I am entitled or I am entitled to claim exempt status.
Signature*
Date*

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Date
Should be Empty:

MISSISSIPPI EMPLOYEE'S WITHHOLDING EXEMPTION CERTIFICATE

Personal Exemptions Allowed