SSN Policy Manual

Policy Manual

Voluntary Withholding Agreement Voluntary Withholding Agreement Form Wm4T I ~erminationor withdrawal from w-4 agreement I (Rev. November 1998) I b Voluntary Withholding Agreemmtc26 C.F.R. gll.3402(p)-l I

Employer identificat!on number

Employer's name and address

Submitted for:

In lieu of W-4, Employee's Withholding Certificate. Employer will not make any payroll withholding. Employee is responsible for all taxes. Termination of previous W-4 agreement. Beginning effective on the last day of pay period in enter n7011th of year

Employee's Liability Rekase Statement:

I , understand that termination or withdrawal of a W-4, Employee's Withholding Certikate, releasesthe employer from any obligation to make payroll withholdings. ~urthermoreI, understand that I am responsible for all taxes due and I release the employer from any tax liability associated with this employee. I certiQ that the foregoing statement is correct and I release the employer from any withholding obligations or claims. Employee's signature b Date b type or minf vour name here

Em~lovee'sinformation

I Social security number (write 'None- if you do not have a SSN or 'Declined" if you do not wish b provide a SSN)

Last name

Type or prinl ernployeelpayee first name and initial

--- -- Home sddrcss (numberand street or rural mute)

Clryor bm. State and ZIPcode

Swc. 3 1.3402@> 1 Voluntary withholding agrcemcnts. (a) In general. An employee and his cmployer may enter into an agreement under section 3402(h) to provide for the withholding of income tax upon payments of amounts described in paragraph (bXI) of Sec. 31.WOl(a)-3, made after December 31, 1970. (b) Form and duration of agreement. (1x1) Except as provided in subdivision (ii) of this subparagraph, an employcr. who desires to cntcr into an ogmcment under slrtion 3402(p) shall fumish his employer with Form W-4 (withholding exemption ceflificolc) exccute. in accordance with the provisions of section 3302(f) and the ~gulationsthereunder. The furnishing of such Form W-4 shall constitute a request for withholding. (c) A statement that the enlployee desires withholding of Fcderal income tax. nnd applicable, of qualified State individual income tax (see paragraph (dX3XI) of Sec. 301.636 1-1 of this chaptcr (Regulations on Procedums and Administmtion)), and (d) If the cmployee dcsiws that the agrwrncnt terminole on o specific daw, the date of 1crmin;ition of the agreement. If acccptcd by thc employer os provided in suhdiviuon (i3) of this subparagraph, the request shall be anached to, and constitute part of, the employee's Form W-4. An employee who furnishes his employer a request for withholding under this suhlivision shall also fumish such employer with Form W-4 ifsuch employee does not olwady have a Form W-4 in eflkt with such cmploycr. (iii) No nxlwst Ibr withholding under section 3302(p) shall be effective 8s nn agrcemnt bc~~nancmgloyerandnnemployee until the employer accepts the mqucst by commencing to withhold fmm the amounts with respect to which thc reqwst was made. (2) An agreement under section 3402 (p) shall be effective for such period as the employer and employec mtdudly agree upon. However. e i k r t h e employeror the employee may terminate the agreement prior to the end of such period by furnishing a signed written notice to the other. Unlcssthcemployr.r nnd employw o g m to an mrlier termination dtc, the notiw shall be elTcctivc with wspct to the first payment of M amount in respect of'which the agreement is in effect which is nude on or after the first "status delcrmination dok" (January I , May 1, July I, md October 1ofeachyear)that occursat least 30 days after the date on which the notice is furnished. If the employee executes a new Form W-4, the request upon which an agcement under section 3402 (p) is based shall be attached to, and constitute a part of, such new Fonn W-4. Public Domain Fo-W-4T