FORM                           MASSACHUSETTS EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE                 Rev. 1/0                                        8   ADEPRTMMATEPE      SIEN SET  SPLAIDNCAACMTHSV BUOSLI ERTFB  EATE    MVTEI ETOTRSEVE   EUN
M-4
Print full name  .......................................................          Social Security no.  .......................................
Print home address...................................................             City.......................  State ...............              Zip  ................

Employee:                                                 HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS
File this form or Form W-4 with1.Your personal exemption. Write the figure “1.” If you are age 65 or over or will be before next year, write “2” .........                                             ........
your employer. Otherwise,
Massachusetts Income Taxes     2.If married and if exemption for spouse is allowed, write the figure “4.” If your spouse is age 65 or over or will
will be withheld from your       be before next year and if otherwise qualified, write “5.” See Instruction C..........................................                                                ........
wages without exemptions.
                               3.Write the number of your qualified dependents. See Instruction D..................................................                                                    ........
Employer:
Keep this certificate with your4.Add the number of exemptions which you have claimed above and write the total .......................................
records. If the employee is    5.Additional withholding per pay period under agreement with employer $ ______________________
believed to have claimed
excessive exemptions, the        A.Check if you will file as head of household on your tax return.
Massachusetts Department
of Revenue should be so          B.Check if you are blind.C.                Check if spouse is blind and not subject to withholding.
advised.                         D.Check if you are a full-time student engaged in seasonal, part-time or temporary employment whose estimated annual income
                                   will not exceed $8,000.
                                 EMPLOYER: DO NOT withhold if Box D is checked.
I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.
Date. . . . . . . . . . . . . . . . . . . . . . . . . . .  Signed ...............................................................................
                                             THIS FORM MAY BE REPRODUCED

                                 THE COMMONWEALTH OF MASSACHUSETTS, DEPARTMENT OF REVENUE
A. Number. If you claim more than the correct number of exemptions, civil         C. Spouse. If your spouse is not working or if she or he is working but not
and criminal penalties may be imposed. You may claim a smaller number of          claiming the personal exemption or the age 65 or over exemption, generally
exemptions. If you do not file a certificate, your employer must withhold on the  you may claim those exemptions in line 2. However, if you are planning to file
basis of no exemptions.                                                           separate annual tax returns, you should not claim withholding exemptions for
                                                                                  your spouse or for any dependents that will not be claimed on your annual tax
If you expect to owe more income tax than will be withheld, you may either        return.
claim a smaller number of exemptions or enter into an agreement with your
employer to have additional amounts withheld.                                     If claiming a wife or husband, write “4” in line 2. Using “4” is the withholding
                                                                                  system adjustment for the $4,400 exemption for a spouse.
You should claim the total number of exemptions to which you are entitled to
prevent excessive overwithholding, unless you have a significant amount of        D. Dependent(s).You may claim an exemption in line 3 for each individual
other income.                                                                     who qualifies as a dependent under the Federal Income Tax Law. In addition,
                                                                                  if one or more of your dependents will be under age 12 at year end, add “1” to
If you work for more than one employer at the same time, you must                 your dependents total for line 3.
not claim any exemptions with employers other than your principal
employer.                                                                         You are not allowed to claim “federal withholding deductions and ad-
                                                                                  justments” under the Massachusetts withholding system.
If you are married and if your spouse is subject to withholding, each may
claim a personal exemption.                                                       If you have income not subject to withholding, you are urged to have
                                                                                  additional amounts withheld to cover your tax liability on such income.
B. Changes.  You may file a new certificate at any time if the number of ex-      See line 5.
emptionsincreases.Y oumust       file a new certificate within 10 days if the num-
ber of exemptions previously claimed by you decreases. For example, if
during the year your dependent son’s income indicates that you will not pro-
vide over half of his support for the year, you must file a new certificate.
                          IF YOU CLAIM THE SAME NUMBER OF EXEMPTIONS FOR MASSACHUSETTS AND U.S. INCOME TAXES, 
                                             COMPLETE U.S. FORM W-4 ONLY.