MO W-4

Missouri Department of Revenue

This certificate is for income tax withholding and child support enforcement purposes only. Type or print.

Full Name

Social Security Number

Address

Home Address (Number and Street or Rural Route)

Street Address Line 2

City or TownState

ZIP Code

1. Filing Status: Check the appropriate filling status below.

Single or Married Spouse Works or Married Filing SeparateMarried (Spouse does not work)Head of Household

2. Additional withholding: If you expect to have a balance due (as a result of interest income, dividends, income from a part-time job, etc on your tax return, you may request your employer to withhold an additional amount of tax from each pay period. To calculate the amount needed, divide the amount of the expected tax by the number of pay periods in a year. Enter the additional amount to be withheld each pay period on line 2.

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3. Reduced withholding: If you expect to receive a refund (as a result of itemized deductions, modifications or tax credits) on your tax return, you may direct your employer to only withhold the amount indicated on line 3. Your employer will not use the standard calculations for withholding. If you designate an amount that is too low, it could result in you being under withheld. To calculate the amount needed, divide the amount of your expected tax by the number of pay periods in a year. Enter the amount to be withheld instead of the standard calculation. If no amount is indicated on line 3, the standard calculations will be used.

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4. Exempt Status: Select the appropriate reason you are claiming an exemption from withholding below and indicate EXEMPT on line 4.

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I am exempt because I had a right to a refund of all Missouri income tax withheld last year and expect to have no tax liability this year. A new MO W-4 must be completed annually if you wish to continue the exemption.I am exempt because I meet the conditions set forth under the Servicemember Civil Relief Act, as amended by the Military Spouses Residency Relief Act and have no Missouri tax liability.I am exempt because my income is earned as a member of any active duty component of the Armed Forces of the United States and I am eligible for the military income deduction.

Under penalties of perjury, I certify that the information provided on this form is true and accurate.

Employee’s Signature (Form is not valid unless you sign it)

Date (MM/DD/YYYY)

Date

Employer’s Name

Address

Employer’s Address

Street Address Line 2

CityState

ZIP Code

Date Services for Pay First Performed by Employee (MM/DD/YYYY)

Date

Federal Employer I.D. Number

Missouri Tax Identification Number

Within 20 days of hiring a new employee, send a copy of Form MO W-4 to the Missouri Department of Revenue, P.O. Box 3340, Jefferson City, MO 65105-3340 or fax to (573) 526-8079.

Please visit http://dss.mo.gov/child-support/employers/new-hire-reporting.htm for additional information regarding new hire reporting.

Visit our online withholding calculator https://mytax.mo.gov/rptp/portal/home/withholding-calculator.

Employees must complete a new form if their filing status changes or to adjust the amount of withholding.

If you are claiming an “Exempt” status due to the Military Spouses Residency Relief Act you must provide one of the following to your employer: Leave and Earnings Statement of the non-resident military servicemember, Form W-2 issued to the nonresident military servicemember, a military identification card, or specific military orders received by the servicemember. You must also provide verification of residency such as a copy of your state income tax return filed in your state of residence, a property tax receipt from the state of residence, a current drivers license, vehicle registration or voter ID card.

Additional information can be found at https://dor.mo.gov/business/.

Mail to: Taxation Division P.O. Box 3340

Phone: (573) 751-8750 Fax: (573) 526-8079

Signature

MO W-4

Employee’s Withholding Certificate

Employee

Signature

Employer