EMPLOYER INFORMATION SHEET

Transcription

1 General EMPLOYER INFORMATION SHEET Business Name: Business Address: City, State, Zip: Filing Name (if different): Filing Address (if different): City, State, Zip: Contact Name: Phone: Fax: Company Type: S-Corp C-Corp LLC LLP Partnership Sole Proprietor 501c3 Other Direct Deposit Employer Bank Routing Number: Employer Bank Account Number: Principal Officer s Name: Principal s Social Security Number: Principal s Date Of Birth: Federal law requires that we store and verify information about the principal officer to help prevent money laundering and the funding of terrorist activity. The principal officer is the person who is the main contact for the bank account from which electronic payments (including direct deposit) are made. Payroll No. of W-2 employees No. of 1099 contractors to be paid through payroll First Date To Run Payroll MM / DD / YY Federal EIN Applied For State Employer Account No. Applied For State Unemployment No. Applied For State Unemployment Insurance Rate % (if known) Other state tax rates, if applicable: Federal Deposit Schedule Monthly Semi-Weekly Other State Deposit Schedule Only applicable to states with income tax Same as federal Other

2 Payroll History Attach any historical payroll information from this calendar year for all active and terminated employees Have not run any payroll yet this year Beginning of Calendar Quarter Start. If you will begin using our service at the start of the 2 nd, 3 rd or 4 th calendar quarter (April 1, July 1, or October 1), please include the following items. Year-to-date wages, taxes, and deductions for each employee Dates and amounts of all payroll tax payments made to date for current year tax liabilities Middle of Calendar Quarter Start. If you will begin using our service in the middle of a calendar quarter, please include the following items. Notes Year-to-date wages, taxes, and deductions for each employee as of the most recent payroll Year-to-date wages, taxes, and deductions for each employee as of the end of the most recent calendar quarter (not applicable if you re starting in the middle of the first calendar quarter) Payroll register or other summary for each payroll date in the current quarter, including total amounts for each wage item, tax, and voluntary deduction on that date. Dates and amounts of all payroll tax payments made to date for current year tax liabilities

3 General Information EMPLOYEE INFORMATION SHEET Complete this form for each employee. Employee Name Birth Date MM /DD /YY Address Hire Date MM /DD /YY City, State, Zip Social Security No. Address Gender Female Male Direct Deposit Information Will this employee be paid by direct deposit? Yes. If so, please complete the Authorization of Direct Deposit form No Tax Information Please attach or specify the following information for this employee: Attach completed federal Form W-4 Attach completed state withholding form. Only applicable if state income tax and filing status/allowances are different from federal Specify any payroll taxes that this employee is exempt from, such as state unemployment, social security, or Medicare: Specify any local taxes that need to be withheld from this employee s paycheck: Notes: Pay Information Which types of pay does this employee receive? Salary $ per Hourly Rates (up to 8 different) Overtime Pay Double Overtime Sick Pay Holiday Pay Vacation Pay Bonus Commission Allowance Reimbursement Cash Tips Paycheck Tips Clergy Housing (Cash) Clergy Housing (In-Kind) Bereavement Pay Group Term Life Insurance S-Corp Owners Health Ins. Personal Use of Company Car Other:

4 Pay Frequency Every Week Every Other Week Payday details Date(s) or day(s) employees paid (for example, the 1 st and 15 th of the month) Twice a Month Every Month Other Period Covered (for example, Paycheck on the 1 st covers the 16 th to the end of the prior month) Payroll Deductions Select the voluntary deductions that apply and enter the $ or % amount to be deducted from each paycheck. Deduction Pre-tax medical Pre-tax vision Pre-tax dental Taxable medical Taxable vision Taxable dental 401(k) Simple 401(k) $ Amount or % of Gross Deduction 403(b) Simple IRA SARSEP Medical expense FSA Dependent care FSA Loan Repayment Cash Advance Repayment Other $ Amount or % of Gross Is this employee subject to wage garnishments, such as a federal tax or child support garnishment? Yes If so, attach copies of all garnishment orders No Sick and Vacation If this employee earns paid time off, complete the section below; otherwise, leave blank. Sick Pay No. of Hours Earned Per Year Max. hours accrued per year (if any) Vacation Pay No. of Hours Earned Per Year Max. hours accrued per year (if any) Current Balance Current Balance Hours are accrued: As a lump sum at the beginning of year Each pay period Each hour worked Hours are accrued: As a lump sum at the beginning of year Each pay period Each hour worked Notes

5 Authorization for Direct Deposit I authorize to deposit my pay automatically to the account(s) indicated below and, if necessary, to adjust or reverse a deposit for any payroll entry made to my account in error. This authorization will remain in effect until I cancel it in writing and in such time as to afford a reasonable opportunity to act on it. Name on bank account: Bank account number: Checking Savings Bank routing number: Amount: $ or entire paycheck: *Balance of pay to: Manual (paper check) Account described below *Note: Split payments are not available for contractors. Name on bank account: Bank account number: Checking Savings Bank routing number: Important: Please attach a voided check for each bank account to which funds should be deposited. Employee/Contractor signature: Date: Payers: Do not send this form with your Direct Deposit enrollment. Keep for your records.

6 Form W-4 (2018) Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. You may claim exemption from withholding for 2018 if both of the following apply. For 2017 you had a right to a refund of all federal income tax withheld because you had no tax liability, and For 2018 you expect a refund of all federal income tax withheld because you expect to have no tax liability. If you re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2018 expires February 15, See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding. General Instructions If you aren t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2018 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. You can also use the calculator at to determine your tax withholding more accurately. Consider using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you re having withheld compares to your projected total tax for If you use the calculator, you don t need to complete any of the worksheets for Form W-4. Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty. Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you re married and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Other Income Worksheet on page 3 or the calculator at W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Specific Instructions Personal Allowances Worksheet Complete this worksheet on page 3 first to determine the number of withholding allowances to claim. Line C. Head of household please note: Generally, you can claim head of household filing status on your tax return only if you re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status. Line E. Child tax credit. When you file your tax return, you might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse, during the year. Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don t qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total income includes all of Form W-4 Department of the Treasury Internal Revenue Service Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records. Employee s Withholding Allowance Certificate Whether you re entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. 1 Your first name and middle initial Last name OMB No Your social security number Home address (number and street or rural route) City or town, state, and ZIP code 3 Single Married Married, but withhold at higher Single rate. Note: If married filing separately, check Married, but withhold at higher Single rate. 4 If your last name differs from that shown on your social security card, check here. You must call for a replacement card. 5 Total number of allowances you re claiming (from the applicable worksheet on the following pages) Additional amount, if any, you want withheld from each paycheck $ 7 I claim exemption from withholding for 2018, and I certify that I meet both of the following conditions for exemption. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write Exempt here Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete. Employee s signature (This form is not valid unless you sign it.) 8 Employer s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.) 9 First date of employment Date 10 Employer identification number (EIN) For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No Q Form W-4 (2018)

7 Form W-4 (2018) Page 2 your wages and other income, including income earned by a spouse, during the year. Line G. Other credits. You might be able to reduce the tax withheld from your paycheck if you expect to claim other tax credits, such as the earned income tax credit and tax credits for education and child care expenses. If you do so, your paycheck will be larger but the amount of any refund that you receive when you file your tax return will be smaller. Follow the instructions for Worksheet 1-6 in Pub. 505 if you want to reduce your withholding to take these credits into account. Deductions, Adjustments, and Additional Income Worksheet Complete this worksheet to determine if you re able to reduce the tax withheld from your paycheck to account for your itemized deductions and other adjustments to income such as IRA contributions. If you do so, your refund at the end of the year will be smaller, but your paycheck will be larger. You re not required to complete this worksheet or reduce your withholding if you don t wish to do so. You can also use this worksheet to figure out how much to increase the tax withheld from your paycheck if you have a large amount of nonwage income, such as interest or dividends. Another option is to take these items into account and make your withholding more accurate by using the calculator at If you use the calculator, you don t need to complete any of the worksheets for Form W-4. Two-Earners/Multiple Jobs Worksheet Complete this worksheet if you have more than one job at a time or are married filing jointly and have a working spouse. If you don t complete this worksheet, you might have too little tax withheld. If so, you will owe tax when you file your tax return and might be subject to a penalty. Figure the total number of allowances you re entitled to claim and any additional amount of tax to withhold on all jobs using worksheets from only one Form W-4. Claim all allowances on the W-4 that you or your spouse file for the highest paying job in your family and claim zero allowances on Forms W-4 filed for all other jobs. For example, if you earn $60,000 per year and your spouse earns $20,000, you should complete the worksheets to determine what to enter on lines 5 and 6 of your Form W-4, and your spouse should enter zero ( -0- ) on lines 5 and 6 of his or her Form W-4. See Pub. 505 for details. Another option is to use the calculator at to make your withholding more accurate. Tip: If you have a working spouse and your incomes are similar, you can check the Married, but withhold at higher Single rate box instead of using this worksheet. If you choose this option, then each spouse should fill out the Personal Allowances Worksheet and check the Married, but withhold at higher Single rate box on Form W-4, but only one spouse should claim any allowances for credits or fill out the Deductions, Adjustments, and Additional Income Worksheet. Instructions for Employer Employees, do not complete box 8, 9, or 10. Your employer will complete these boxes if necessary. New hire reporting. Employers are required by law to report new employees to a designated State Directory of New Hires. Employers may use Form W-4, boxes 8, 9, and 10 to comply with the new hire reporting requirement for a newly hired employee. A newly hired employee is an employee who hasn t previously been employed by the employer, or who was previously employed by the employer but has been separated from such prior employment for at least 60 consecutive days. Employers should contact the appropriate State Directory of New Hires to find out how to submit a copy of the completed Form W-4. For information and links to each designated State Directory of New Hires (including for U.S. territories), go to employers. If an employer is sending a copy of Form W-4 to a designated State Directory of New Hires to comply with the new hire reporting requirement for a newly hired employee, complete boxes 8, 9, and 10 as follows. Box 8. Enter the employer s name and address. If the employer is sending a copy of this form to a State Directory of New Hires, enter the address where child support agencies should send income withholding orders. Box 9. If the employer is sending a copy of this form to a State Directory of New Hires, enter the employee s first date of employment, which is the date services for payment were first performed by the employee. If the employer rehired the employee after the employee had been separated from the employer s service for at least 60 days, enter the rehire date. Box 10. Enter the employer s employer identification number (EIN).

8 Form W-4 (2018) Page 3 Personal Allowances Worksheet (Keep for your records.) A Enter 1 for yourself A B Enter 1 if you will file as married filing jointly B C Enter 1 if you will file as head of household C D Enter 1 if: D { You re single, or married filing separately, and have only one job; or } You re married filing jointly, have only one job, and your spouse doesn t work; or Your wages from a second job or your spouse s wages (or the total of both) are $1,500 or less. E Child tax credit. See Pub. 972, Child Tax Credit, for more information. If your total income will be less than $69,801 ($101,401 if married filing jointly), enter 4 for each eligible child. If your total income will be from $69,801 to $175,550 ($101,401 to $339,000 if married filing jointly), enter 2 for each eligible child. If your total income will be from $175,551 to $200,000 ($339,001 to $400,000 if married filing jointly), enter 1 for each eligible child. If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter E F Credit for other dependents. If your total income will be less than $69,801 ($101,401 if married filing jointly), enter 1 for each eligible dependent. If your total income will be from $69,801 to $175,550 ($101,401 to $339,000 if married filing jointly), enter 1 for every two dependents (for example, -0- for one dependent, 1 if you have two or three dependents, and 2 if you have four dependents). If your total income will be higher than $175,550 ($339,000 if married filing jointly), enter F G Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet here.. G H Add lines A through G and enter the total here H For accuracy, complete all worksheets that apply. { If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you have a large amount of nonwage income and want to increase your withholding, see the Deductions, Adjustments, and Additional Income Worksheet below. If you have more than one job at a time or are married filing jointly and you and your spouse both work, and the combined earnings from all jobs exceed $52,000 ($24,000 if married filing jointly), see the Two-Earners/Multiple Jobs Worksheet on page 4 to avoid having too little tax withheld. If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 above. Deductions, Adjustments, and Additional Income Worksheet Note: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of nonwage income. 1 Enter an estimate of your 2018 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 7.5% of your income. See Pub. 505 for details $ 2 Enter: { $24,000 if you re married filing jointly or qualifying widow(er) $18,000 if you re head of household $12,000 if you re single or married filing separately } $ 3 Subtract line 2 from line 1. If zero or less, enter $ 4 Enter an estimate of your 2018 adjustments to income and any additional standard deduction for age or blindness (see Pub. 505 for information about these items) $ 5 Add lines 3 and 4 and enter the total $ 6 Enter an estimate of your 2018 nonwage income (such as dividends or interest) $ 7 Subtract line 6 from line 5. If zero, enter -0-. If less than zero, enter the amount in parentheses... 7 $ 8 Divide the amount on line 7 by $4,150 and enter the result here. If a negative amount, enter in parentheses. Drop any fraction Enter the number from the Personal Allowances Worksheet, line H above Add lines 8 and 9 and enter the total here. If zero or less, enter -0-. If you plan to use the Two-Earners/ Multiple Jobs Worksheet, also enter this total on line 1, page 4. Otherwise, stop here and enter this total on Form W-4, line 5, page

9 Form W-4 (2018) Page 4 Two-Earners/Multiple Jobs Worksheet Note: Use this worksheet only if the instructions under line H from the Personal Allowances Worksheet direct you here. 1 Enter the number from the Personal Allowances Worksheet, line H, page 3 (or, if you used the Deductions, Adjustments, and Additional Income Worksheet on page 3, the number from line 10 of that worksheet) Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you re married filing jointly and wages from the highest paying job are $75,000 or less and the combined wages for you and your spouse are $107,000 or less, don t enter more than If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter -0- ) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet Note: If line 1 is less than line 2, enter -0- on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill. 4 Enter the number from line 2 of this worksheet Enter the number from line 1 of this worksheet Subtract line 5 from line Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here $ 8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed... 8 $ 9 Divide line 8 by the number of pay periods remaining in For example, divide by 18 if you re paid every 2 weeks and you complete this form on a date in late April when there are 18 pay periods remaining in Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck $ Table 1 Table 2 Married Filing Jointly All Others Married Filing Jointly All Others If wages from LOWEST paying job are Enter on line 2 above $0 - $5, ,001-9, ,501-19, ,001-26, ,501-37, ,001-43, ,501-55, ,001-60, ,001-70, ,001-75, ,001-85, ,001-95, , , , , , , , , , , , , , , ,001 and over 19 If wages from LOWEST paying job are Enter on line 2 above $0 - $7, ,001-12, ,501-24, ,501-31, ,501-39, ,001-55, ,001-70, ,001-85, ,001-90, , , , , , , , , , , , , , , , , ,001 and over 17 If wages from HIGHEST paying job are Enter on line 7 above $0 - $24,375 $420 24,376-82, , , , ,325 1, , ,325 1, , ,325 1, ,326 and over 1,540 If wages from HIGHEST paying job are Enter on line 7 above $0 - $7,000 $420 7,001-36, ,176-79, , ,975 1, , ,475 1, , ,475 1, ,476 and over 1,540 Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You aren t required to provide the information requested on a form that s subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return. If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

10 2018 Minnesota Employee Withholding Allowance/Exemption Certificate Employees You must complete and give this form to your employer if you do any of the following: Claim fewer Minnesota withholding allowances than your federal allowances Claim more than 10 Minnesota withholding allowances Want additional Minnesota tax withheld from your pay each pay period Claim to be exempt from federal withholding or claim to be exempt from Minnesota withholding Do not complete this form if you are claiming the same number of Minnesota allowances as federal and the number claimed is 10 or less. Employee s first name and initial Last name Employee s Social Security number W-4MN Permanent address Marital status (check one box) Single; Married, but legally separated; or Spouse is a nonresident alien City State ZIP code Married Section 2 Exemption from Minnesota withholding Complete Section 2 if you claim to be exempt from Minnesota income tax withholding (see Section 2 instructions for qualifications). If applicable, check one box below to indicate the reason why you believe you are exempt: I meet the requirements and claim exempt from both federal and Minnesota income tax withholding. Even though I did not claim exempt from federal withholding, I claim exempt from Minnesota withholding because I had no Minnesota income tax liability last year, I received a refund of all Minnesota income tax withheld, AND I expect to have no Minnesota income tax liability this year. My spouse is a military service member assigned to a military location in Minnesota, my domicile (legal residence) is in another state, AND I am in Minnesota solely to be with my spouse. My state of domicile is. I am an American Indian living and working on a reservation. Married, but withhold at higher Single rate Employees: Read instructions on back, complete Section 1 OR Section 2, sign and give the completed form to your employer. (Do not complete both Section 1 and Section 2. Completing both sections will make the form invalid.) Section 1 Determining Minnesota allowances Complete Section 1 if you claim fewer Minnesota allowances than your federal allowances, AND/OR if you want additional Minnesota withholding deducted each pay period. 1 Total number of federal allowances claimed on federal Form W Total number of Minnesota allowances (line 2 cannot be more than line 1) Additional Minnesota withholding you want deducted each pay period... 3 $ I am a member of the Minnesota National Guard or an active duty U.S. military member and claim exempt from Minnesota withholding on my military pay. I receive a military pension or other military retirement pay as calculated under Title 10, 1401 through 1414, 1447 through 1455, and and claim exempt from Minnesota withholding on this retirement pay. I certify that all information provided in Section 1 OR Section 2 is correct. I understand there is a $500 penalty for filing a false withholding allowance/exemption certificate. Employee s signature Date Daytime phone Employees: Give the completed form to your employer. Employers If you are required to send a copy of this form to the Department of Revenue (see instructions), you must enter the employer information below and mail this form to: Minnesota Revenue, Mail Station 6501, St. Paul, MN (Incomplete forms are considered invalid.) A $50 penalty may be assessed for each required Form W-4MN not filed with the department. Keep a copy for your records. Name of employer Federal employer ID number (FEIN) Minnesota tax ID number Address City State ZIP code (Rev. 12/17) Questions? Website: withholding.tax@state.mn.us. Phone: or

11 Form W-4MN Instructions Do not complete this form if you are claiming the same number of Minnesota allowances as federal and the number claimed is 10 or less. Employee Instructions Should I complete Form W-4MN? Complete Form W-4MN and provide it to your employer, if you do any of the following: Claim fewer Minnesota allowances than federal allowances (You may not claim more Minnesota allowances than federal allowances) Claim more than 10 Minnesota allowances Request additional Minnesota withholding be deducted each pay period Claim to be exempt from Minnesota income tax withholding (see Section 2 instructions) Before you complete Form W-4MN, determine the number of federal withholding allowances you are claiming on federal Form W-4. Then, determine the number of your Minnesota withholding allowances. Consider completing a new Form W-4MN if your personal or financial situation changes. If you have not had sufficient income tax withheld from your wages, interest and/or penalty charges may be assessed when you file your individual income tax return. Your employer may be required to submit copies of your Form W-4MN to the department. Note: You may be subject to a $500 penalty if you submit a false Form W-4MN. Section 1 Minnesota Allowances Claim the correct number of allowances. If you expect to owe more income tax for the year than will be withheld: claim fewer allowances request additional Minnesota taxes to be withheld from your wages (complete line 3) Section 2 Minnesota Exemption Your employer will not withhold Minnesota taxes from your pay if you are exempt from withholding. To claim exemption, you must meet one of the following requirements: You meet the federal requirements; you claim exempt from federal withholding on Form W-4; you had no Minnesota income tax liability in the prior year; you received a full refund of Minnesota tax withheld; and you expect to have no Minnesota income tax liability for the current year. You are the spouse of a military member assigned to duty in Minnesota, you and your spouse are domiciled in another state (the same state as one another) and are present in Minnesota solely to be with your active duty military member spouse. You are a member of an American Indian tribe living and working on the reservation of which you are an enrolled member. Your wages are for Minnesota National Guard (MNG) pay or for active duty U.S. military pay. MNG and active duty U.S. military members can claim exempt from Minnesota withholding on these wages, even if taxable federally. For additional information, see Income Tax Fact Sheet 5, Military Personnel. You receive a military pension or other military retirement pay calculated under Title 10, 1401 through 1414, 1447 through 1455, and If you receive this income, you may claim exempt from Minnesota withholding on this income even if taxable federally. Note: In order to avoid owing tax at the end of the year, you may not want to claim exempt if you (and/or your spouse when filing a joint return) expect to have other forms of income subject to Minnesota tax. If you claim exempt from Minnesota withholding, you must provide your employer with a new Form W-4MN by February 15th of each year. If another person can claim you as a dependent on his or her federal tax return, you cannot claim exempt from Minnesota withholding if your annual income exceeds $950 and includes more than $300 of unearned income. Use of Information All information on Form W-4MN is private by state law. It cannot be given to others without your consent, except to the Internal Revenue Service and to other states that guarantee the same privacy. Your name, address and Social Security number are required for identification. Information about your allowances is required to determine your correct tax. We ask for your phone number so we can call you if we have a question. Employer instructions are on the next page.

12 Form W-4MN Instructions Employer Instructions All new employees must complete federal Form W-4 when they first begin work for you. Some employees must also complete Form W-4MN. Should my employee complete Form W-4MN? Do not have your employee complete Form W-4MN if all of the following apply: They claim 10 or fewer federal allowances and claim the same number of Minnesota allowances as federal They are not requesting additional Minnesota taxes be withheld from their wages They are not claiming to be exempt from Minnesota withholding Employees who complete Form MWR should not complete Form W-4MN. When determining Minnesota withholding for employees who do not need to complete Form W-4MN, use the same number of allowances the employee listed on Form W-4. You are not required to verify the number of allowances claimed by each employee. For more information, see When to Complete under Employee Instructions. Keep all forms in your records. Honor each Form W-4MN you receive unless we notify you otherwise, or if the employee claims more Minnesota than federal allowances. If the employee claims more Minnesota than federal allowances, use the number of federal allowances to determine the Minnesota withholding (see Section 1). How should I determine Minnesota withholding for an employee that doesn t complete Forms W-4 or W-4MN? Withhold Minnesota tax as if the employee is single with zero withholding allowances. If your employee claims exempt from Min-nesota withholding, they must provide you with a new Form W-4MN by Feb. 15 of each year. Exempt forms received during the year must be submitted to the department within 30 days of receipt from the employee. Do I need to send a copy of Form W- 4MN to the department? Send copies of Form W-4MN to the department if any of the following apply: The employee claims more than 10 Minnesota withholding allowances The employee claims to be exempt from Minnesota withholding and you reasonably expect the employee s wages to exceed $200 per week (Exception: If the employee is a resident of a reciprocity state and has completed Form MWR) You believe the employee is not entitled to the number of allowances claimed You do not need to submit the Form W- 4MN to the department if the employee is asking to have additional Minnesota withholding deducted from their pay or is claiming fewer Minnesota withholding allowances than federal. A $50 penalty may be assessed for each required Form W-4MN not filed with the department. Invalid Forms W-4MN The following situations make the Form W-4MN invalid: Any unauthorized change or addition to the form, including any change to the language certifying the form is correct If, by the date an employee gives it to you, he or she indicates in any way the form is false The form is incomplete or lacks the necessary signatures Both Section 1 AND Section 2 were completed The employer information is incomplete What do I do if I receive an invalid Form W-4MN? Do not use it to figure Minnesota income tax withholding. Tell the employee it is invalid and they must complete and submit a new one. If the employee does not give you a valid one, withhold taxes as if the employee was single and claiming zero withholding allowances. However, if you have an earlier Form W-4MN for this worker that is valid, withhold as you did before. Questions? Go to for additional forms and information, fact sheets, and answers to frequently asked questions. withholding.tax@state.mn.us Phone: or This information is available in alternate formats.

13 General Information CONTRACTOR INFORMATION SHEET Complete this form for each 1099 contractor. Contractor Type: Individual Business Contractor Name Address City, State, Zip Address Social Security No./ Employer Identification No. Direct Deposit Information Will this contractor be paid by direct deposit? Yes No If so, complete the Authorization of Direct Deposit form. Pay Information Has this contractor already been paid this calendar year? Yes If so, enter the total compensation and/or reimbursement amounts that you have paid the contractor during the current year. No Compensation amount $ Reimbursement amount $ NOTES

14 Form W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. Give Form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. 2 Business name/disregarded entity name, if different from above 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: Individual/sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/estate Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner. Other (see instructions) 5 Address (number, street, and apt. or suite no.) 6 City, state, and ZIP code 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from FATCA reporting code (if any) (Applies to accounts maintained outside the U.S.) Requester s name and address (optional) 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter. Social security number or Employer identification number Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3. Sign Here Signature of U.S. person General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following: Form 1099-INT (interest earned or paid) Form 1099-DIV (dividends, including those from stocks or mutual funds) Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) Form 1099-S (proceeds from real estate transactions) Form 1099-K (merchant card and third party network transactions) Date Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) Form 1099-C (canceled debt) Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2. By signing the filled-out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information. Cat. No X Form W-9 (Rev )