State Tax Withholding Form

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

Employee Information

• Full Name
• Employee ID
• State for Withholding

Withholding Election

• State Filing Status
• Number of Allowances
  Enter the number of state withholding allowances you are claiming, if applicable.
• Additional Amount to Withhold per Pay Period
  Optional extra amount to withhold from each paycheck.

Exemption Details

• Are you claiming exemption from state withholding?
• Exemption Reason
  Briefly explain the basis for your exemption claim, if required by your state.
• Exemption Expiration Date
  If your exemption expires, enter the date it ends.

Employee Certification

• I certify that the information provided is true and correct to the best of my knowledge.
• Employee Signature
• Date Signed