45. Are you a new employee?
9. Employee's Signature
Home Address (No., Street, P.O. Box or Rural Route)
43. Type or Print Your First Name, Middle Initial and Last Name
EMPLOYEE'S MICHIGAN WITHHOLDING EXEMPTION CERTIFICATE
STATE OF MICHIGAN - DEPARTMENT OF TREASURY
MI-W4
(Rev. 7-03)
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.
Date
11. Federal Employer Identification Number
Enter the number of personal and dependency exemptions you are claiming
Additional amount you want deducted from each pay
(if employer agrees)
I claim exemption from withholding because (see instructions):
6.
7.
8.
a.
b.
c.
EMPLOYEE:
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
records.
INSTRUCTIONS TO EMPLOYER:
Employers must report all new hires to the State
of Michigan. Keep a copy of this certificate with
your records. If the employee claims more than
nine personal and dependency exemptions or
claims a status exempting the employee from
withholding, you must file their original MI-W4
form with the Michigan Department of Treasury.
$ .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 License Number
6.
7.
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: _________________________________
Yes
No
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
withheld.
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 dependency 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.
For more information on Renaissance Zones call the Michigan
Tele-Help System, 1-800-827-4000, and listen to topic 293.
Full-time students cannot claim exempt status.
Web Site
Visit the Treasury Web site at:
www.michigan.gov/treasury
INSTRUCTIONS TO EMPLOYEE
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 more than nine dependency
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
(mo/day/year).
Line 6: Personal and dependency 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.
41. Social Security Number
4
4
4
4
2. Date of Birth
City or Town State Zip Code
