5. Are you a new employee?
9. Employee's Signature
Home Address (No., Street, P.O. Box or Rural Route)
3. Type or Print Your First Name, Middle Initial and Last Name
(Rev. 08-11)
This certificate is for Michigan income tax withholding purposes only. You must file a revised form within 10 days if your exemptions decrease or your residency status changes
from nonresident to resident. Read instructions below before completing this form.
Issued under P.A. 281 of 1967.
Under penalty of perjury, I certify that the number of withholding exemptions claimed on this certificate does not
exceed the number to which I am entitled. If claiming exemption from withholding, I certify that I anticipate that I
will not incur a Michigan income tax liability for this year.
11. Federal Employer Identification Number
Enter the number of personal and dependent exemptions you are claiming
Additional amount you want deducted from each pay
(if employer agrees)
If you fail or refuse to file this form, your
employer must withhold Michigan income tax
from your wages without allowance for any
exemptions. Keep a copy of this form for your
Employers must report all new hires to the State
of Michigan. Keep a copy of this certificate with
your records. If the employee claims 10 or more
personal and dependent exemptions or claims a
status exempting the employee from
withholding, you must file their original MI-W4
form with the Michigan Department of Treasury.
Mail to: New Hire Operations Center, P.O. Box
85010; Lansing, MI 48908-5010.
$ .00
Employer: Complete lines 10 and 11 before sending to the Michigan Department of Treasury.
10. Employer's Name, Address, Phone No. and Name of Contact Person
4. Driver's License Number or State ID
A Michigan income tax liability is not expected this year.
Wages are exempt from withholding. Explain: _______________________________________________________
Permanent home (domicile) is located in the following Renaissance Zone: _________________________________
If Yes, enter date of hire . . . .
If you hold more than one job, you may not claim the same
exemptions with more than one employer. If you claim the
same exemptions at more than one job, your tax will be under
Line 7: You may designate additional withholding if you expect
to owe more than the amount withheld.
Line 8: You may claim exemption from Michigan income tax
withholding ONLY if you do not anticipate a Michigan income
tax liability for the current year because all of the following
exist: a) your employment is less than full time, b) your
personal and dependent exemption allowance exceeds your
annual compensation, c) you claimed exemption from federal
withholding, d) you did not incur a Michigan income tax liability
for the previous year. You may also claim exemption if your
permanent home (domicile) is located in a Renaissance Zone
or you are a non-resident spouse of military personnel
stationed in Michigan. Members of flow-through entities may
not claim exemption from nonresident flow-through
withholding. For more information on Renaissance Zones call
(517) 636-4486. Full-time students that do not satisfy all of the
above requirements cannot claim exempt status.
Visit the Treasury Web site at: www.michigan.gov/taxes
You must submit a Michigan withholding exemption
certificate (form MI-W4) to your employer on or before the date
that employment begins. If you fail or refuse to submit this
certificate, your employer must withhold tax from your
compensation without allowance for any exemptions. Your
employer is required to notify the Michigan Department of
Treasury if you have claimed 10 or more personal and
dependent exemptions or claimed a status which exempts you
from withholding.
You MUST file a new MI-W4 within 10 days if your residency
status changes or if your exemptions decrease because: a)
your spouse, for whom you have been claiming an exemption,
is divorced or legally separated from you or claims his/her own
exemption(s) on a separate certificate, or b) a dependent must
be dropped for federal purposes.
Line 5: If you check "Yes," enter your date of hire
Line 6: Personal and dependent exemptions. The total number
of exemptions you claim on the MI-W4 may not exceed the
number of exemptions you are entitled to claim when you file
your Michigan individual income tax return.
If you are married and you and your spouse are both
employed, you both may not claim the same exemptions with
each of your employers.
1. Social Security Number
2. Date of Birth
City or Town State ZIP Code
I claim exemption from withholding because (does not apply to nonresident members of flow-through entities - see instructions):
Reset Form
Lake Superior State University
650 W Easterday Avenue
Sault Ste Marie, MI 49783
Attn: Ashley Bishop