Effective January 1, 2022

Employees: See Employee General Instructions on Page 2. Sign and return Form CT-W4 tp your employer. Keep a copy for your records.
1. Withholding Code: Enter the Withholding Code letter chosen from above:*
2. Additional withholding amount per pay period: If any, see instructions:*
3. Reduced withholding amount per pay period: If any, see instructions:*
Other
Name*

First Name and Middle InitialLast Name
Social Security Number:*
Home Address*

Number and Street, Apartment number, Suite number, PO Box

Street Address Line 2

CityState / Province

Postal / 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 fi ve years, or both.
Employee’s signature

Clear
Date*

MonthDayYear
Date
Employers: See Employer Instructions on Page 2.
NoYes
Enter date hired*

MonthDayYear
Date
Employer's Business Name:
Federal Employer Identification Number:
Employer's Business Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person:
Name and Position
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: