State Tax Withholding Form

Collects employee state tax withholding details, including filing status, allowances, additional withholding, and exemption claims.

Employee Information

• Employee Name
• Employee ID
  Optional if your payroll system can match you by name and work email.
• Work Email
• State for Withholding

Withholding Election

• Filing Status
• Allowances Claimed
  Enter the number of allowances or withholding units claimed, if applicable for your state.
• Additional Withholding Per Pay Period
  Optional extra amount to withhold from each paycheck.
• Additional Withholding Frequency
  Choose how often the additional withholding amount should be applied.

Exemption and Special Claims

• Are you claiming exemption from state withholding?
• Exemption Reason
• Exemption Explanation
  Provide a brief explanation or reference to the state rule supporting the exemption claim.

Employee Certification

• I understand that the information provided will be used to calculate state tax withholding and may be shared with payroll administrators as needed.
• Employee Signature
• Date Signed