FORM                             MASSACHUSETTS WITHHOLDING EXEMPTION CERTIFICATE                                                                 Rev. 1/0 8   DEPARTMMAEPETIEEN SST SPLAACNIDMACTHSV BOULSIBEFRTATEETMTI EE VORTSEVEENU
M-4P                    FOR PENSION, ANNUITYAND OTHER PERIODIC AND NONPERIODIC PAYMENTS
Print full name  .......................................................       Social Security no.  .......................................
Print home address...................................................          City.......................  State ...............                Zip  ................

Send this form to                                       HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS
the payer of your       1.  Your personal exemption. Write the figure “1.” If you are age 65 or over or will be before next year, write “2”      .........                          ........
pension or other        2.  If married and if exemption for spouse is allowed, write the figure “4.” If your spouse is age 65 or over or will
subject payment.            be before next year and if otherwise qualified, write “5.” See Instruction C..........................................                                  ........
                        3.  Write the number of your qualified dependents. See Instruction D..................................................                                      ........
                        4.  Add the number of exemptions which you have claimed above and write the total .......................................
                        5.  Additional withholding per pay period under agreement with employer $ ______________________
                            A.   Check if you will file as head of household on your tax return.
                            B.   Check if you are blind.C.                  Check if spouse is blind and not subject to withholding.
                            D.   Check if you are exempt from Massachusetts income tax withholding because your legal residence (domicile) is elsewhere and
                                 your pension is from certain pension plans (see instruction E).
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
The Massachusetts income tax withholding provisions apply to pension, an-      C. Spouse. If your spouse is not working or if she or he is working but not
nuity and other periodic and nonperiodic payments made to those who have       claiming the personal exemption or the age 65 or over exemption, generally
not elected to be exempt from the U.S. income tax withholding provisions.      you may claim those exemptions in line 2. However, if you are planning to file
                                                                               separate annual tax returns, you should not claim withholding exemptions
A. Number.If you claim more than the correct number of exemptions, civil       for your spouse or for any dependents that will not be claimed on your annual
and criminal penalties may be imposed. You may claim a smaller number of       tax return.
exemptions. If you do not file a certificate, Massachusetts withholding will be
based on “0” exemptions.                                                       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.
If you expect to owe more income tax than will be withheld, you may either
claim a smaller number of exemptions or enter into an agreement with your      D. Dependent(s). You may claim an exemption in line 3 for each individual
payer to have additional amounts withheld.                                     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
You should claim the total number of exemptions to which you are entitled to   your dependents total for line 3.
prevent excessive overwithholding — unless you have a significant amount of
other income.                                                                  E. Payments not subject to tax   Under Title 4 of the United States Code, sec-
                                                                               tion 114, payments to nonresidents of Massachusetts from certain pension
If you or your spouse are claiming exemptions under Massachusetts              plans are not subject to tax.
withholding from other income (such as employment), do not claim the
same exemptions from this income.                                              If you elect not to have U.S. income tax withholding apply to pensions, other
                                                                               periodic and nonperiodic payments in the future, Massachusetts law provides
B. Changes.  You may file a new certificate at any time if the number of ex-   that Massachusetts withholding will cease on such payments.
emptionsincreases.Y oumust  file a new certificate within 10 days if the num-
ber of exemptions previously claimed by you decreases. For example, if         If you have income not subject to withholding, you are urged to have
during the year your dependent son’s income indicates that you will not pro-   additional amounts withheld to cover your tax liability on such income.
vide over half of his support for the year, you must file a new certificate.   See line 5.