W4-MN

Complete Form W-4MN so that your employer can withhold the correct Minnesota income tax from your pay. Consider completing a new Form W-4MN each year or when your personal or financial situation changes.

Employee’s First Name and Initial*

Employee’s Last Name*

Employee’s Social Security Number*

Permanent Address*

City*

State*

ZIP Code*

Single; Married, but legally separated; or Spouse is a nonresident alienMarriedMarried, but withhold at higher Single rate

Section 1 — Select this section to determine Minnesota allowances. Complete the following questions A-F.

A) Enter “1” if no one else can claim you as a dependent.

If none, enter 0.

B) Enter “1” if any of the following apply: a) You are single and have only one job, b) You are married, have only one job, and your spouse does not work, c) Your wages from a second job or your spouse’s wages are $1500 or less

If none, enter 0.

C) Enter “1” if you are married. You may choose to enter “0” if you are married and have either a working spouse or more than one job. (Entering “0” may help you avoid having too little tax withheld.)

D) Enter the number of dependents (other than your spouse or yourself) you will claim on your tax return.

If none, enter 0.

E) Enter “1” if you will use the filing status Head of Household.

If none, enter 0.

F) Total number of allowances claimed. Steps A-E will automatically calculate here.

1. Minnesota Allowances. Answer from Section 1F above will automatically show here.

2. Additional Minnesota withholding you want deducted each pay period.

Section 2 — Select this section if you are selecting to be exempt From Minnesota Withholding

A) I meet the requirements and claim exempt from both federal and Minnesota income tax withholdingB) Even though I did not claim exempt from federal withholding, I claim exempt from Minnesota withholding, because: •I had no Minnesota income tax liability last year •I received a refund of all Minnesota income tax withheld •I expect to have no Minnesota income tax liability this yearC) All of these apply: •My spouse is a military service member assigned to a military location in Minnesota •My domicile (legal residence) is in another state •I am in Minnesota solely to be with my spouse.D) I am an American Indian that resides and works on a reservationE) I am a member of the Minnesota National Guard or an active duty U.S. military member and claim exempt from Minnesota withholding on my military payF) I receive a military pension or other military retirement pay as calculated under U.S. Code, title 10, sections 1401 through 1414, 1447 through 1455, and 12733, and I claim exempt from Minnesota withholding on this retirement pay

I certify that all information provided in Section 1 OR Section 2 is correct. I understand there is a $500 penalty for filing a false Form W-4MN.

Signature*

Date*

Date

Phone Number*

Format: (000) 000-0000.

W4-MN

Minnesota Allowances and Additional Withholding