CT-W4

Form CT-W4 Instructions

Enter date hired

Are you a new or rehired employee?

NoYes

Married Filing Jointly

	Our expected combined annual gross income is less than or equal to $24,000 or I am claiming exemption under the Military Spouses Residency Relief Act (MSRRA)* and no withholding is necessary.	My spouse is employed and our expected combined annual gross income is greater than $24,000 and less than or equal to $100,500. See Certain Married Individuals, Page 2.	My spouse is not employed and our expected combined annual gross income is greater than $24,000.	My spouse is employed and our expected combined annual gross income is greater than $100,500	I have significant nonwage income and wish to avoid having too little tax withheld.	I am a nonresident of Connecticut with substantial other income.
Select One

Married Filing Separately

	My expected annual gross income is less than or equal to $12,000 or I am claiming exemption under the MSRRA* and no withholding is necessary	My expected annual gross income is greater than $12,000.	I have significant nonwage income and wish to avoid having too little tax withheld.	I am a nonresident of Connecticut with substantial other income.
Select One

Single

	My expected annual gross income is less than or equal to $15,000 and no withholding is necessary	My expected annual gross income is greater than $15,000.	I have significant nonwage income and wish to avoid having too little tax withheld.	I am a nonresident of Connecticut with substantial other income.
Select One

Head of Household

	My expected annual gross income is less than or equal to $19,000 and no withholding is necessary	My expected annual gross income is greater than $19,000.	I have significant nonwage income and wish to avoid having too little tax withheld.	I am a nonresident of Connecticut with substantial other income.
Select One

Qualifying Widow(er)

	My expected annual gross income is less than or equal to $24,000 or I am claiming exemption under the MSRRA* and no withholding is necessary.	My expected annual gross income is greater than $24,000.	I have significant nonwage income and wish to avoid having too little tax withheld.	I am a nonresident of Connecticut with substantial other income.
Select One

Check if you are claiming the MSRRA exemption and enter state of legal residence/domicile:

If claiming MSRRA exemption enter state of legal residence/domicile:

1. Withholding Code: Automatically entered based on your selection above*

2. Additional withholding amount per pay period: If any, see instructions.

3. Reduced withholding amount per pay period: If any, see instructions.

Name*

First NameLast Name

MI

Email

example@example.com

Social Security Number

Home address (number and street, apartment number, suite number, PO Box)*

City/town*

State

ZIP code*

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.

Employee's signature

Date

Employer's business name

Federal Employer Identification Number

Employer Address

E.A City

E.A. State

E.A. Zip

Contact person

Telephone Prefix

Telephone 1

Telephone 2

CT-W4

Select the filing status you expect to report on your Connecticut income tax return: