W-4S R equest for Federal Income Tax Withholding From Sick Pa

Form

W-4S

Request for Federal Income Tax
Withholding From Sick Pay

Department of the Treasury
Internal Revenue Service

©

OMB No. 1545-0074

2009

Give this form to the third-party payer of your sick pay.

Type or print your first name and middle initial.

Your social security number

Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

Claim or identification number (if any)
I request federal income tax withholding from my sick pay payments. I want the following amount to be withheld from
each payment. (See Worksheet below.)

Employee’s signature

©

Date

$

©

Cut here and give the top part of this form to the payer. Keep the lower part for your records.

Worksheet (Keep for your records. Do not send to the Internal Revenue Service.)
1

Enter amount of adjusted gross income that you expect in 2009

1

2

If you plan to itemize deductions on Schedule A (Form 1040), enter the estimated total of your deductions.
For 2009, you may have to reduce your itemized deductions if your income is over $166,800
($83,400 if married filing separately). See Pub. 919, How Do I Adjust My Tax Withholding, for details. Call
1-800-829-3676 or visit the IRS website at www.irs.gov to order forms and publications. If you do not plan
to itemize deductions, enter the standard deduction, including additional amounts for age and blindness, and
any additional standard deduction for real estate taxes or a disaster loss

2

3

Subtract line 2 from line 1

3

4

Exemptions. Multiply $3,650 by the number of personal exemptions. For 2009, your personal exemption(s)
amount is reduced if your income is over $166,800 if single, $250,200 if married filing jointly or qualifying
widow(er), $125,100 if married filing separately, or $208,500 if head of household. See Pub. 919 for details

4

5

Subtract line 4 from line 3

5

6

Tax. Figure your tax on line 5 by using the 2009 Tax Rate Schedule X, Y, or Z on page 2. Do not use the Tax
Table or Tax Rate Schedule X, Y, or Z in the 2008 Form 1040, 1040A, or 1040EZ instructions

6

7

Credits (child tax and higher education credits, credit for child and dependent care expenses, etc.)

7

8

Subtract line 7 from line 6

8

9

Estimated federal income tax withheld and to be withheld from other sources (including amounts withheld
due to a prior Form W-4S) during 2009 or paid with Form 1040-ES

9

10

Subtract line 9 from line 8

10

11

Enter the number of sick pay payments you expect to receive this year to which this Form W-4S will apply

11

12

Divide line 10 by line 11. Round to the nearest dollar. This is the amount that should be withheld from each
sick pay payment. Be sure it meets the requirements for the amount that should be withheld, as explained
under Amount to be withheld below. If it does, enter this amount on Form W-4S above

12

General Instructions
Purpose of form. Give this form to the third-party payer of your sick
pay, such as an insurance company, if you want federal income tax
withheld from the payments. You are not required to have federal
income tax withheld from sick pay paid by a third party. However, if
you choose to request such withholding, Internal Revenue Code
sections 3402(o) and 6109 and their regulations require you to
provide the information requested on this form. Do not use this form
if your employer (or its agent) makes the payments because
employers are already required to withhold federal income tax from
sick pay.
Note. If you receive sick pay under a collective bargaining
agreement, see your union representative or employer.
Definition. Sick pay is a payment that you receive:
● Under a plan to which your employer is a party and
● In place of wages for any period when you are temporarily
absent from work because of your sickness or injury.
Amount to be withheld. Enter on this form the amount that you
want withheld from each payment. The amount that you enter:
For Paperwork Reduction Act Notice, see page 2.

● Must be in whole dollars (for example, $35, not $34.50).
● Must be at least $4 per day, $20 per week, or $88 per month
based on your payroll period.
● Must not reduce the net amount of each sick pay payment that
you receive to less than $10.
For payments larger or smaller than a regular full payment of sick
pay, the amount withheld will be in the same proportion as your
regular withholding from sick pay. For example, if your regular full
payment of $100 a week normally has $25 (25%) withheld, then $20
(25%) will be withheld from a partial payment of $80.
Caution. You may be subject to a penalty if your tax payments
during the year are not at least 90% of the tax shown on your tax
return. For exceptions and details, see Pub. 505, Tax Withholding
and Estimated Tax. You may pay tax during the year through
withholding or estimated tax payments or both. To avoid a penalty,
make sure that you have enough tax withheld or make estimated tax
payments using Form 1040-ES, Estimated Tax for Individuals. You
may estimate your federal income tax liability by using the worksheet
above.
(continued on back)
Cat. No. 10226E

Form

W-4S

(2009)

Form W-4S (2009)

Page

Sign this form. Form W-4S is not valid unless you sign it.
Statement of income tax withheld. After the end of the year, you
will receive a Form W-2, Wage and Tax Statement, reporting the
taxable sick pay paid and federal income tax withheld during the
year. These amounts are reported to the Internal Revenue Service.
Changing your withholding. Form W-4S remains in effect until you
change or revoke it. You may do this by giving a new Form W-4S or
a written notice to the payer of your sick pay. To revoke your
previous Form W-4S, complete a new Form W-4S and write
“Revoked” in the money amount box, sign it, and give it to the
payer.

Specific Instructions for Worksheet
You may use the worksheet on page 1 to estimate the amount of
federal income tax that you want withheld from each sick pay
payment. Use your tax return for last year and the worksheet as a
basis for estimating your tax, tax credits, and withholding for this
year.
You may not want to use Form W-4S if you already have your total
tax covered by estimated tax payments or other withholding.
If you expect to file a joint return, be sure to include the income,
deductions, credits, and payments of both yourself and your spouse
in figuring the amount you want withheld.
Caution. If any of the amounts on the worksheet change after you
give Form W-4S to the payer, you should use a new Form W-4S to
request a change in the amount withheld.

Line 2—Deductions
Itemized deductions. You may have to reduce your itemized
deductions if your income is over $166,800 ($83,400 if married filing
separately). See Pub. 919 for details.
Standard deduction. For 2009, the standard deduction amounts
are:
Standard
Filing Status
Deduction
Married filing jointly or qualifying widow(er)

$11,400*

Head of household

$8,350*

Single or Married filing separately

$5,700*

2

*If you are age 65 or older or blind, add to the standard deduction
amount the additional amount that applies to you as shown in the
next paragraph. If you can be claimed as a dependent on another
person’s return, see Limited standard deduction for dependents
below.
Additional amount for the elderly or blind. An additional
standard deduction of $1,100 is allowed for a married individual
(filing jointly or separately) or qualifying widow(er) who is 65 or older
or blind, $2,200 if 65 or older and blind. If both spouses are 65 or
older or blind, an additional $2,200 is allowed on a joint return
($2,200 on a separate return if you can claim an exemption for your
spouse). If both spouses are 65 or older and blind, an additional
$4,400 is allowed on a joint return ($4,400 on a separate return if you
can claim an exemption for your spouse). An additional $1,400 is
allowed for an unmarried individual (single or head of household)
who is 65 or older or blind, $2,800 if 65 or older and blind.
Limited standard deduction for dependents. If you can be
claimed as a dependent on another person’s return, your standard
deduction is the greater of (a) $950 or (b) your earned income plus
$300 (up to the regular standard deduction for your filing status). If
you are 65 or older or blind, see Pub. 505 for additional amounts
that you may claim.
Certain individuals not eligible for standard deduction. For the
following individuals, the standard deduction is zero.
● A married individual filing a separate return if either spouse
itemizes deductions.
● A nonresident alien individual.
● An individual filing a return for a period of less than 12 months
because of a change in his or her annual accounting period.

Line 7—Credits
Include on this line any tax credits that you are entitled to claim,
such as the child tax and higher education credits, credit for child
and dependent care expenses, earned income credit, or credit for
the elderly or the disabled.

Line 9—Tax Withholding and Estimated Tax
Enter the federal income tax that you expect will be withheld this
year on income other than sick pay and any payments that you
made using Form 1040-ES. Include any federal income tax withheld
and to be withheld from wages and pensions.

2009 Tax Rate Schedules
Schedule X—Single
If line 5 is:
Over—

$0
8,350
33,950
82,250
171,550
372,950

Schedule Z—Head of household
The tax is:

But not
over—

$8,350
33,950
82,250
171,550
372,950
and greater

$0
$835.00
4,675.00
16,750.00
41,754.00
108,216.00

+
+
+
+
+
+

10%
15%
25%
28%
33%
35%

If line 5 is:

of the
amount
over—

Over—

$0
8,350
33,950
82,250
171,550
372,950

$0
11,950
45,500
117,450
190,200
372,950

The tax is:
But not
over—

$11,950
45,500
117,450
190,200
372,950
and greater

$0
$1,195.00
6,227.50
24,215.00
44,585.00
104,892.50

+
+
+
+
+
+

10%
15%
25%
28%
33%
35%

of the
amount
over—

$0
11,950
45,500
117,450
190,200
372,950

Schedule Y-1—Married filing jointly or Qualifying widow(er)

Schedule Y-2—Married filing separately

If line 5 is:

If line 5 is:

Over—

$0
16,700
67,900
137,050
208,850
372,950

But not
over—

$16,700
67,900
137,050
208,850
372,950
and greater

The tax is:

$0
$1,670.00
9,350.00
26,637.50
46,741.50
100,894.50

+
+
+
+
+
+

10%
15%
25%
28%
33%
35%

of the
amount
over—

Over—

$0
16,700
67,900
137,050
208,850
372,950

$0
8,350
33,950
68,525
104,425
186,475

Paperwork Reduction Act Notice. We ask for the information on
this form to carry out the Internal Revenue laws of the United States.
You are not required to provide the information requested on a
form that is subject to the Paperwork Reduction Act unless the form
displays a valid OMB control number. Books or records relating to a
form or its instructions must be retained as long as their contents
may become material in the administration of any Internal Revenue
law. Generally, tax returns and return information are confidential, as
required by Code section 6103.

But not
over—

$8,350
33,950
68,525
104,425
186,475
and greater

The tax is:

$0
$835.00
4,675.00
13,318.75
23,370.75
50,447.25

+
+
+
+
+
+

10%
15%
25%
28%
33%
35%

of the
amount
over—

$0
8,350
33,950
68,525
104,425
186,475

The average time and expenses required to complete and file this
form will vary depending on individual circumstances. For estimated
averages, see the instructions for your income tax return.
If you have suggestions for making this form simpler, we would be
happy to hear from you. See the instructions for your income tax
return.