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LW-4 ___ RESIDENT
EMPLOYEE'S WITHHOLDING CERTIFICATE FOR CITY OF LAPEER INCOME TAX ___ NONRESIDENT
1. Print Full Name Social Security # Office, Plant, Department Employee Identification #
2. Address, Number and Street City, Township or Village State Zip Code
MI
3. Predominant Place of Employment City
Print Name of each city where you work Under 25% 40% 60% 80% 100%
for this employer and circle % of total City
earnings of each. Under 25% 40% 60% 80% 100%
YOUR WITHHOLDING 4. Exemption for Regular $600 Additional exemption Additional exemption Enter Number of
EXEMPTIONS: yourself: exemption if 65 or over at end of year if blind Exemptions Checked: Æ
Check blocks which apply 5. Exemption for Regular $600 Additional exemption Additional exemption Enter Number of
spouse: exemption if 65 or over at end of year if blind Exemptions Checked: Æ
EMPLOYEE: File this form with 6. (a) Exemptions for Number 6. (b) Exemptions for your Number Enter total of Line 6
your employer. Otherwise he must your children other dependents (a+b) Æ
withhold City of Lapeer Income Tax 7. Add the number of exemptions which you have claimed on lines 4, 5 and 6 above and write the total Æ
from your earnings without
exemption.
EMPLOYER: Keep this certificate 8. Additional amount you want deducted from each pay (if employer agrees) Æ .00
with your records. If the information I certify that the information submitted on this certificate is true, correct, and complete to the best of my knowledge and
submitted by the employee is not belief.
believed to be true; correct and 9. Date Signature:
complete the form, and the City
must be advised.
FORM LW-4 - INSTRUCTIONS FOR COMPLETING EMPLOYEE’S WITHHOLDING CERTIFICATE
GENERAL INSTRUCTIONS-Check the line in the upper • Your uncle, aunt, nephew or niece (but only if
right hand corner to indicate your residency status and related by blood).
enter the requested data on lines 1 and 2
CHANGES IN EXEMPTIONS: You should file a new
LINE 3 INSTRUCTIONS: If you work for this employer certificate at any time if the number of your exemptions
in more than two cities or communities, print names of INCREASES. You must file a new certificate within 10
the two Michigan cities or communities where you days if the number of exemptions previously claimed by
perform the greatest percent of your work. Circle the you DECREASES for any of the following reasons:
closest percent of total earnings for work done or (a) Your wife (or husband) for whom you have been
services rendered in each city or community listed. The claiming exemption is divorced or legally separated
estimated percent of total earnings from this employer or claims her (or his) own exemption on a separate
for work done or services performed within taxing cities certificate.
is for withholding purposes only. In determining final tax (b) The support of a dependent for whom you
liability this estimate is subject to substantiation and claimed exemption is taken over by someone else
audit. so that you no longer expect to furnish more than
half the support for the year.
DEPENDENTS; To qualify as your dependent (line6), a (c) You find that a dependent for whom you claimed
person (a) must receive more than one-half of his or her exemption will receive $600 or more of income on
support from you for the year, and (b) must have less his own during the year (except your child who is a
than $600 gross income during the year (except your student who is under 19 years of age).
child who is a student or who is under 19 years of age),
and (c) must not be claimed as an exemption by such OTHER DECREASES in exemption, such as the death
person's husband or wife, and (d) must be a citizen or of a wife or a dependent, do not affect your withholding
resident of the United States or a resident of Canada, until the next year, but require the filing of a new
Mexico, the Republic of Panama, or the Canal Zone (this certificate by December 1 of the year in which they
does not apply to an alien child legally adopted by and occur.
living with a United States citizen abroad), and (e) must
(1) have your home as his principal residence and be a CHANGE OF RESIDENCE- You must file a new
member of your household for the entire year, or (2) be certificate within 10 days after you change your
related to you as follows: residence from or to a taxing city.
• Your son or daughter (including legally adopted CHANGES IN EMPLOYMENT – You must file a new
children), grandchild, stepson, stepdaughter, son-in- certificate by December 1 of each year if your Line 3
law, or daughter-in-law; estimate of the percent of work done or services to be
• Your father, mother, grandparent, stepfather, rendered in cities levying an income tax will change for
stepmother, father-in-law, or mother-in-law; the ensuing year.
• Your brother, sister, stepbrother, stepsister, half
brother, half sister, brother-in-law, or sister-in-law;
Revised 8-1-08
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