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. 11-19)
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,
you are a non-resident spouse of military personnel stationed in
Michigan, or you are a member of a Native American tribe that
has a tax agreement with the State of Michigan and whose
principal place of residence is within the designated agreement
area. 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.
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):
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