1. Filing Status: Check the appropriate filling status below.
r Single or Married Spouse Works or Married Filing Separate r Married (Spouse does not work)
r Head of Household
2. Additional withholding: If you expect to have a balance due (as a result of interest income, dividends, income from a
part-time job, etc.) on your tax return, you may request your employer to withhold an additional amount of tax from each
pay period. To calculate the amount needed, divide the amount of the expected tax by the number of pay periods in a
year. Enter the additional amount to be withheld each pay period on line 2..................................... 2
Reduced withholding: If
you expect to receive a refund (as a result of itemized deductions, modifications or tax credits)
on your tax return, you may direct your employer to only withhold the amount indicated on line 3. Your employer
will not use the standard calculations for withholding.
If you designate an amount that is too low, it could result in you
being under withheld. To calculate the amount needed, divide the amount of your expected tax by the number of pay
periods in a year. Enter the amount to be withheld instead of the standard calculation. If no amount is indicated on
line 3, the standard calculations will be used............................................................. 3
4. Exempt Status: Select the appropriate reason you are claiming an exemption from withholding below and indicate
EXEMPT on line 4. ................................................................................ 4
r I am exempt because I had a right to a refund of all Missouri income tax withheld last year and expect to have no tax liability
this year. A new MO W-4 must be completed annually if you wish to continue the exemption.
r I am exempt because I meet the conditions set forth under the Servicemember Civil Relief Act, as amended by the
Military Spouses Residency Relief Act and have no Missouri tax liability.
r I am exempt because my income is earned as a member of any active duty component of the Armed Forces of the
United States and I am eligible for the military income deduction.
This certificate is for income tax withholding and child support enforcement purposes only. Type or print.
Notice To Employer:
Within 20 days of hiring a new employee, send a copy of Form MO W-4 to the Missouri Department of Revenue, P.O. Box 3340, Jefferson City, MO
65105-3340 or fax to (573) 526-8079.
Please visit http://dss.mo.gov/child-support/employers/new-hire-reporting.htm for additional information regarding new hire reporting.
Notice to Employee:
Return completed form to your Employer. Consider completing a new Form MO W-4 each year and when your personal or financial situation changes.
Visit our online withholding calculator https://mytax.mo.gov/rptp/portal/home/withholding-calculator.
Items to Remember:
• Employees must complete a new form if their filing status changes or to adjust the amount of withholding.
• If you are claiming an “Exempt” status due to the Military Spouses Residency Relief Act you must provide one of the following to your employer: Leave
and Earnings Statement of the non-resident military servicemember, Form W-2 issued to the nonresident military servicemember, a military
identification card, or specific military orders received by the servicemember. You must also provide verification of residency such as a copy of
your state income tax return filed in your state of residence, a property tax receipt from the state of residence, a current drivers license, vehicle
registration or voter ID card. For additional assistance in regard to Military, visit the department’s website https://dor.mo.gov/military/.
• Additional information can be found at https://dor.mo.gov/business/withhold/.
Employer’s Name Employer’s Address
City State ZIP Code
Date Services for Pay First Performed by Employee (MM/DD/YYYY) Federal Employer I.D. Number Missouri Tax Identification Number
| | | | | | | | | | | | | | |
__ __ / __ __ / __ __ __ __
Full Name Social Security Number
Home Address (Number and Street or Rural Route) City or Town State ZIP Code
Under penalties of perjury, I certify that the information provided on this form is true and accurate.
Employee’s Signature (Form is not valid unless you sign it) Date (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
Mail to: Taxation Division Phone: (573) 522-0967
P.O. Box 3340 Fax: (573) 526-8079
Jefferson City, MO 65105-3340
Form MO W-4 (Revised12-2019)
Employee’s Withholding Certificate