Michigan Withholding Certificate (MI-W4)

Michigan Withholding Certificate (MI-W4)

Complete this form to provide your Michigan income tax withholding information to your employer.
Full Social Security Number
Date of Birth

MonthDayYear
Date
Name (First, Middle Initial, Last)
Driver’s License Number or State ID
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City or Town
State
ZIP Code
Are you a new employee?
If Yes, enter date of hire

MonthDayYear
Date
Number of personal and dependent exemptions
Additional amount you want deducted from each pay
Exemption reason: A Michigan income tax liability is not expected this year
Exemption reason: Wages are exempt from withholding
Wages exempt from withholding - Explain
Exemption reason: Permanent home (domicile) is located in the following Renaissance Zone
Renaissance Zone - Describe location
Employee’s Signature
Date (Employee signature date)

MonthDayYear
Date
Employer’s Name
Federal Employer Identification Number
Employer Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Employer City or Town
Employer State
Employer ZIP Code
Name of Contact Person
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: