Form W-4 S Request for Federal Income Tax Withholding From Sick Pay

Form

W-4S

Request for Federal Income Tax
Withholding From Sick Pay

Department of the Treasury
Internal Revenue Service

▶

OMB No. 1545-0074

2012

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

Type or print your first name and middle initial.

Last 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 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 ▶
Separate 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 2012 . . . . . . . . . . . . . . .
2 If you plan to itemize deductions on Schedule A (Form 1040), enter the estimated total of your deductions. If you
do not plan to itemize deductions, enter the standard deduction, including additional amounts for age and
blindness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 Subtract line 2 from line 1 . . . . . . . . . . . . .
4 Exemptions. Multiply $3,800 by the number of personal exemptions

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

1

2
3
4

5 Subtract line 4 from line 3 . . . . . . . . . . . . . . . . . . . . . . . . . .
6 Tax. Figure your tax on line 5 by using the 2012 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 2011 Form 1040, 1040A, or 1040EZ instructions . . . . . .

5

7 Credits (child tax and higher education credits, credit for child and dependent care expenses, etc.) . . . .
8 Subtract line 7 from line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .
9 Estimated federal income tax withheld or to be withheld from other sources (including amounts withheld due to a
prior Form W-4S) during 2012 or paid or to be paid with 2012 estimated tax payments . . . . . . . .

7
8

10 Subtract line 9 from line 8 . . . . . . . . . . . . . . . . . . . . . . . .
11 Enter the number of sick pay payments you expect to receive this year to which this Form W-4S will apply

.
.

.
.

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 . . . . . . . . . .

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.

6

9
10
11

12

• 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 (2012)

Page 2

Form W-4S (2012)

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
Standard deduction. For 2012, the standard deduction amounts are:
Standard
Filing Status
Deduction
Married filing jointly or qualifying widow(er) . . . . . . $11,900*
Head of household . . . . . . . . . . . . .
$8,700*
Single or Married filing separately
. . . . . . . .
$5,950*
*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, later.

Additional amount for the elderly or blind. An additional standard
deduction of $1,150 is allowed for a married individual (filing jointly or
separately) or qualifying widow(er) who is 65 or older or blind, $2,300 if
65 or older and blind. If both spouses are 65 or older or blind, an
additional $2,300 is allowed on a joint return ($2,300 on a separate
return if you can claim an exemption for your spouse). If both spouses
are 65 or older and blind, an additional $4,600 is allowed on a joint
return ($4,600 on a separate return if you can claim an exemption for
your spouse). An additional $1,450 is allowed for an unmarried individual
(single or head of household) who is 65 or older or blind, $2,900 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 made or to be made
with 2012 estimated tax payments. Include any federal income tax
already withheld or to be withheld from wages and pensions.
Future developments. The IRS has created a page on IRS.gov for
information about Form W-4S and its instructions, at www.irs.gov/w4s.
Information about any future developments affecting Form W-4S (such
as legislation enacted after we release it) will be posted on that page.

2012 Tax Rate Schedules
Schedule X—Single
If line 5 is:
Over—

$0
8,700
35,350
85,650
178,650
388,350

But not
over—

$8,700
35,350
85,650
178,650
388,350
and greater

Schedule Z—Head of household
The tax is:
$0 + 10%
$870 + 15%
4,867.50 + 25%
17,442.50 + 28%
43,482.50 + 33%
112,683.50 + 35%

of the
amount
over—

If line 5 is:
Over—

$0
8,700
35,350
85,650
178,650
388,350

$0
12,400
47,350
122,300
198,050
388,350

But not
over—

$12,400
47,350
122,300
198,050
388,350
and greater

The tax is:
$0 + 10%
$1,240 + 15%
6,482.50 + 25%
25,220 + 28%
46,430 + 33%
109,229 + 35%

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
17,400
70,700
142,700
217,450
388,350

But not
over—

$17,400
70,700
142,700
217,450
388,350
and greater

The tax is:
$0 + 10%
$1,740 + 15%
9,735 + 25%
27,735 + 28%
48,665 + 33%
105,062 + 35%

of the
amount
over—

$0
17,400
70,700
142,700
217,450
388,350

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

Over—

$0
8,700
35,350
71,350
108,725
194,175

But not
over—

$8,700
35,350
71,350
108,725
194,175
and greater

The tax is:
$0 + 10%
$870 + 15%
4,867.50 + 25%
13,867.50 + 28%
24,332.50 + 33%
52,531 + 35%

of the
amount
over—

$0
12,400
47,350
122,300
198,050
388,350

of the
amount
over—

$0
8,700
35,350
71,350
108,725
194,175

returns and return information are confidential, as required by Code
section 6103.
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.