Department of Health and Human Services
Public Health Service Commissioned Corps
PUBLIC HEALTH SERVICE COMMISSIONED OFFICER’S
STATE TAX WITHHOLDING ALLOWANCE CERTIFICATE
1. First Name
(Type or Print)
Middle Initial Last Name 2. Your Social Security Number
Home Address (Number and Street or Rural Route)
3. Marital Status:
Single
Married
Married, but withhold at higher Single rate.
City or Town, State, and Zip Code
NOTE:
If married, but legally separated, or spouse is
a nonresident alien, check the Single box.
4. Total number of allowances you are claiming
4
5. Additional amount, if any, you want deducted from each pay
5
$
6. I claim exemption from withholding and I certify that I meet ALL of the following conditions for exemptions:
Last year I had a right to a refund of ALL State income tax withheld because I had NO tax liability; AND
.
This year I expect a refund of ALL State income tax withheld because I expect to have NO tax liability; AND
.
This year if my income exceeds $500 and includes nonwage income, another person cannot claim me as a dependent.
.
If you meet all of the above conditions, enter the year effective and "EXEMPT" here
6
YEAR:
7. Are you a full-time student? (Note: Full-time students are not automatically exempt.)
Yes7 No
Under penalties of perjury, I certify that I am entitled to the number of withholding allowances claimed on this certificate or entitled to claim exempt status.
Employee’s Signature:
Effective Date
Month, Day, Year
8. Employer’s name and address
Department of Health and Human Services
Program Support Center
Office of Commissioned Corps Support Services/HRS
ATTN: Compensation Branch
5600 Fishers Lane, Room 4-50
Rockville, MD 20857-0001
USE FOR
STATE TAX ONLY
STATE OF
Public Health Service Commissioned Officer’s
State Tax Withholding Allowance Certificate
PHS-6353
Privacy Act Notice
This statement is provided pursuant to the Privacy Act of 1974 (5 U.S.C. 552a). Our authority to collect this
information is 37 U.S.C. 403; 42 U.S.C. 202 et seq.; and Executive Order 9397, "Numbering System for Federal
Accounts Relating to Individual Persons."
The information provided on this form will become part of record systems 09-40-0001, "PHS Commissioned Corps
General Personnel Records," HHS/PSC/HRS, and 09-40-0010, "Pay, Leave and Attendance Records,"
HHS/PSC/HRS.
This information is used to certify entitlement to the number of State withholding allowances claimed on the
certificate or entitlement to claim exempt status for State withholding allowance purposes. This information will be
used only as necessary in personnel and pay administration processes carried out in accordance with established
regulations and published notices of systems of records. Copies of these systems of records may be obtained by
contacting the office to which you submit this form.
Effects of Nondisclosure: Disclosure of the Social Security Account Number (SSAN) is mandatory under provisions
of Executive Order 9397 to obtain benefits and services as or on behalf of a commissioned officer. The SSAN is
also used to distinguish a record from those commissioned officers who may have similar names and dates of birth.
Failure to provide the information will result in accumulating a State taxable wage based on the individual’s home of
record. All statements are subject to verification.
PHS-6353-1 (Rev. 03/05)
PSC Publishing Services (301) 443-6740
EF
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