Employee’s Withholding Certificate
13. Employer’s Business Name
14. Connecticut Tax Registration Number
15. Employer’s Business Address
16. Federal Employer Identification Number
19. Zip Code
20. Contact Person
21. Telephone Number
Employers Must Complete Items 12 through 21. Please print clearly.
12. Is this a new or rehired employee?
If yes, provide the date of hire
4. First Name
5. Home Address
6. Your Social Security Number
9. Zip Code
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 that the penalty for reporting false information is a fine of not more than $5,000, or imprisonment for not more than five years, or both.
10. Employee’s Signature
Employer Instructions On Reverse
M M D D Y Y
Department of Revenue Services
State of Connecticut
Effective January 1, 2005
Complete this form so your employer can withhold the correct amount of Connecticut income tax from your wages.
• Go to the chart below that describes the filing status you expect to report on your federal income tax return. (Armed Forces Personnel and
Veterans, see Special Instructions for Armed Forces Personnel and Veterans, Page 2)
• Choose the statement that best describes your income. (Gross income means income from all sources.) Enter the Withholding Code in Step 2, Line 1.
• Complete Step 2. Sign, make a copy for yourself, and return the original to your employer.
• For more information, see Employee Instructions on Page 2.
Step 2 - Complete Lines 1 through 11.
Step 1 - Determine your Withholding Code.
My expected annual gross income is less than or equal to
$12,000 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