EmailMe Form - MI-W4 EMPLOYEE'S MICHIGAN WITHHOLDING

Tax Year *

Last Four Digits of your Social Security Number *

Date of Birth *

MM / DD / YYYY

Name *

First Last

Driver License Number *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Are you a new employee? *

Yes

No

If Yes, enter the date of hire

MM / DD / YYYY

Enter the number of personal and dependent exemptions you are claiming *

Additional amount you want deducted from each pay (if employer agrees)

$ Dollars . Cents

I claim exemption from withholding because (does not apply to nonresident members of flow-through entities - see instructions)

A Michigan income tax liability is not expected this year

Wages are exempt from withholding

Permanent home (domicile) is located in the following Renaissance Zone

Todays Date *

MM / DD / YYYY

Signature *

Use your finger if you are using a Mobile Phone or Tablet. You can also use your computer mouse to sign your name.