Request for State Income Tax 
                                                        Withholding From Sick Pay 
                                                        File this form with the payer of your sick pay. 

Type or Print Your Full Name                                                                                                                                                                                               Your Social Security Number 

Home Address (Number and Street or Rural Route) 

City or Town, State, and ZIP Code 

Claim or Identification Number (If Any)   .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  

I request income tax withholding from my sick pay payments. I want the following amount to be withheld from each payment   .  .  .  .  .  .   $ 

Employee’s Signature                                                                                                    Date 

 ----------------------------------------------------   Detach along this line. Give the top part of this form to the payer; keep the lower part for your records.  -------------------------------------------------  

General Instructions 

The Information Practices Act Notice: Information                                           Amount to Be Withheld: Enter on this form the 
collected is for the purpose of administering the                                           amount you want withheld from each payment. 
Personal Income Tax law under the authority of                                              You can use the worksheet accompanying the state 
Section 13028.6 of the                                  California Unemployment             Employee's Withholding Allowance Certificate 
Insurance Code and Section 4328.6-1 of Title 22,                                            (DE 4) to estimate the amount of income tax you 
California Code of Regulations.                                                             want withheld from each sick pay payment. 

Purpose of Form: To request state income tax                                                Sign This Form: The DE 4S is not valid unless you 
withholding from sick pay. File this form ONLY if                                           sign it. 
the sick pay is received from a third party, such as 
an insurance company or trust. You do not have to                                           Statement of Income Tax Withheld: After the end 
file this form if you receive sick pay from your                                            of the year, you will receive a Wage and Tax 
employer as you have previously submitted a                                                 Statement (Form W-2) reporting the taxable sick 
withholding form.                                                                           pay paid and income tax withheld during the prior 
                                                                                            year. These amounts may be included on your 
You may not want to use the DE 4S form if you                                               Form W-2 with your other wages and withholding. 
already have all your tax liability covered by 
estimated tax payments or other withholding.                                                Changing Your Withholding: The DE 4S remains 
                                                                                            in effect until you change or cancel it. You can do 
Definition: Sick pay is a payment you receive:                                              this by giving a new DE 4S or a written notice to 
                                                                                            the payer of your sick pay. 
(a) Under a plan your employer takes part in.
(b) In place of wages for any period when
you are temporarily absent from work
because of sickness or injury.

DE 4S Rev. 1 (7-15) (INTERNET)                                                  Page 1 of 1                                                                                                                                CU