Employee’s Withholding Certificate
4. First Name
5. Home Address
6. Your Social Security Number
9. 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, or imprisonment for not more than five years, or both.
10. Employee’s Signature
Department of Revenue Services
State of Connecticut
Effective February 24, 2006
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. Civil Unions see Civil Union, Page 2.)
• Choose the statement that best describes your gross income. (See Gross Income, Page 2) 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, 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.
Our expected combined annual gross income is less than or
equal to $24,000 and no withholding is necessary.
Our expected combined annual gross income is greater
than $24,000 and less than or equal to $100,500. (See Special
Rules for Certain Married or Civil Union Individuals, Page 2.)
My spouse is not employed and our expected combined
annual gross income is greater than $24,000.