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

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Form

W-4S

Request for Federal Income Tax
Withholding From Sick Pay

▶

Department of the Treasury
Internal Revenue Service

▶

OMB No. 1545-0074

2022

Give this form to the third-party payer of your sick pay.
Go to www.irs.gov/FormW4S for the latest information.

Your first name and middle initial

Your social security number

Last name

Home address (number and street or rural route)

DRAFT AS OF
October 27, 2021
DO NOT FILE

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 IRS.)

1 Enter amount of adjusted gross income that you expect in 2022

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2 If you plan to itemize deductions on Schedule A (Form 1040), enter the estimated total of your
deductions. See Pub. 505 for details. If you don’t plan to itemize deductions, enter the standard
deduction. (See the instructions on page 2 for the standard deduction amount, including additional
standard deductions for age and blindness.) Note: There is no deduction for personal exemptions for
2022 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3 Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . .
4 Tax. Figure your tax on line 3 by using the 2022 Tax Rate Schedule X, Y-1, Y-2, or Z on page 2. Do not
use any tax tables, worksheets, or schedules in the 2021 Instructions for Form 1040
. . . . . .
5 Credits (child tax and higher education credits, credit for child and dependent care expenses, etc.) . .
6 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . .
7 Estimated federal income tax withheld or to be withheld from other sources (including amounts withheld
due to a prior Form W-4S) during 2022 or paid or to be paid with 2022 estimated tax payments . . .
8 Subtract line 7 from line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .
9 Enter the number of sick pay payments you expect to receive this year to which this Form W-4S will
apply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10 Divide line 8 by line 9. 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 aren’t 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. Don’t 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’re 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:
• 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.
For Paperwork Reduction Act Notice, see page 2.

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5
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8
9

10

• 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 aren’t 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.
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’ll
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 IRS.

(continued on back)
Cat. No. 10226E

Form W-4S (2022)

Page 2

Form W-4S (2022)

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

Additional standard deduction for the elderly or blind. An
additional standard deduction of $X,XXX is allowed for a married
individual (filing jointly or separately) or a qualifying widow(er) who is
65 or older or blind, $X,XXX if 65 or older and blind. If both spouses
are 65 or older or blind, an additional $X,XXX is allowed on a joint
return. If both spouses are 65 or older and blind, an additional $X,XXX
is allowed on a joint return. Additional standard deductions are also
allowed on your separate return for your spouse who is 65 or older
and/or blind if your spouse has no gross income and can’t be claimed
as a dependent by another taxpayer. An additional $X,XXX is allowed
for an unmarried individual (single or head of household) who is 65 or
older or blind, $X,XXX if 65 or older and blind. See the 2022 Estimated
Tax Worksheet—Line 2 Standard Deduction Worksheet in Pub. 505.
Limited standard deduction for dependents. If you are a
dependent of another person, your standard deduction is the greater
of (a) $X,XXX or (b) your earned income plus $XXX (up to the regular
standard deduction for your filing status). If you’re 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. For exceptions, see Pub. 519, U.S.
Tax Guide for Aliens.
• An individual filing a return for a period of less than 12 months
because of a change in his or her annual accounting period.

DRAFT AS OF
October 27, 2021
DO NOT FILE

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. Itemized deductions include qualifying home
mortgage interest, charitable contributions, state and local taxes (up
to $10,000), and medical expenses in excess of 7.5% of your
adjusted gross income. See Pub. 505 for details.
Standard deduction. For 2022, the standard deduction amounts are:
Standard
Filing Status
Deduction

Married filing jointly or qualifying widow(er) . . . . . $XX,XXX*
Head of household . . . . . . . . . . . . $XX,XXX*
Single or Married filing separately . . . . . . . . $XX,XXX*
* If you’re 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.

Line 5—Credits

Include on this line any tax credits that you’re entitled to claim, such
as the child tax credit and credit for other dependents, higher
education credits, credit for child and dependent care expenses,
earned income credit, or credit for the elderly or the disabled. See
the Tax Credits table in Pub. 505 for more information.

Line 7—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 2022 estimated tax payments. Include any federal income
tax already withheld or to be withheld from wages and pensions.

2022 Tax Rate Schedules
Schedule X—Single
If line 3 is:
Over—

$X
X,XXX
XX,XXX
XX,XXX
XXX,XXX
XXX,XXX
XXX,XXX

But not
over—

$X,XXX
XX,XXX
XX,XXX
XXX,XXX
XXX,XXX
XXX,XXX
and greater

Schedule Z—Head of household
The tax is:
$X + 10%
XXX + 12%
X,XXX + 22%
XX,XXX + 24%
XX,XXX + 32%
XX,XXX + 35%
XXX,XXX.XX + 37%

of the
amount
over—

$X
X,XXX
XX,XXX
XX,XXX
XXX,XXX
XXX,XXX
XXX,XXX

If line 3 is:
Over—

$X
XX,XXX
XX,XXX
XX,XXX
XXX,XXX
XXX,XXX
XXX,XXX

But not
over—

$XX,XXX
XX,XXX
XX,XXX
XXX,XXX
XXX,XXX
XXX,XXX
and greater

The tax is:
$X + 10%
X,XXX + 12%
X,XXX + 22%
XX,XXX + 24%
XX,XXX + 32%
XX,XXX + 35%
XXX,XXX + 37%

of the
amount
over—

$X
XX,XXX
XX,XXX
XX,XXX
XXX,XXX
XXX,XXX
XXX,XXX

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

Schedule Y-2—Married filing separately

If line 3 is:

If line 3 is:

Over—

$X
XX,XXX
XX,XXX
XXX,XXX
XXX,XXX
XXX,XXX
XXX,XXX

But not
over—

$XX,XXX
XX,XXX
XXX,XXX
XXX,XXX
XXX,XXX
XXX,XXX
and greater

The tax is:
$X + 10%
X,XXX + 12%
X,XXX + 22%
XX,XXX + 24%
XX,XXX + 32%
XX,XXX + 35%
XXX,XXX.XX + 37%

of the
amount
over—

$X
XX,XXX
XX,XXX
XXX,XXX
XXX,XXX
XXX,XXX
XXX,XXX

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

Over—

$X
X,XXX
XX,XXX
XX,XXX
XXX,XXX
XXX,XXX
XXX,XXX

But not
over—

$X,XXX
XX,XXX
XX,XXX
XXX,XXX
XXX,XXX
XXX,XXX
and greater

The tax is:
$X + 10%
XXX + 12%
X,XXX + 22%
XX,XXX + 24%
XX,XXX + 32%
XX,XXX + 35%
XX,XXX.XX + 37%

of the
amount
over—

$X
X,XXX
XX,XXX
XX,XXX
XXX,XXX
XXX,XXX
XXX,XXX

law. Generally, tax 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.