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

Version A, Cycle 3

Form

W-4S

Request for Federal Income Tax
Withholding From Sick Pay

OMB No. 1545-0074

2023

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

Department of the Treasury
Internal Revenue Service
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:

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 2023 . . . . . . . . . . . . .
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 2023 . . . . . . . .

1

INTERNAL USE ONLY
DRAFT AS OF
November 7, 2022

3 Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . .
4 Tax. Figure your tax on line 3 by using the 2023 Tax Rate Schedule X, Y-1, Y-2, or Z on page 2. Do not
use any tax tables, worksheets, or schedules in the 2022 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 2023 or paid or to be paid with 2023 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.
• Must not reduce the net amount of each sick pay payment that
you receive to less than $10.
For Paperwork Reduction Act Notice, see page 2.

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5
6
7
8
9

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.
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.

(continued on back)
Cat. No. 10226E

Form W-4S (2023)

Version A, Cycle 3
Page 2

Form W-4S (2023)

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. 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 2023, the standard deduction amounts are:
Standard
Filing Status
Deduction
Married filing jointly or qualifying surviving spouse . . . $27,700*
Head of household . . . . . . . . . . . . $20,800*
Single or Married filing separately . . . . . . . . $13,850*
* 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.
Additional standard deduction for the elderly or blind. An
additional standard deduction of $1,500 is allowed for a married
individual (filing jointly or separately) or a qualifying surviving spouse
who is 65 or older or blind, $3,000 if 65 or older and blind. If both

spouses are 65 or older or blind, an additional $3,000 is allowed on
a joint return. If both spouses are 65 or older and blind, an
additional $6,000 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 $1,850 is allowed for an unmarried individual (single or
head of household) who is 65 or older or blind, $3,700 if 65 or older
and blind. See the 2023 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) $1,250 or (b) your earned income plus $400 (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.

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.

INTERNAL USE ONLY
DRAFT AS OF
November 7, 2022
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 2023 estimated tax payments. Include any federal income
tax already withheld or to be withheld from wages and pensions.

2023 Tax Rate Schedules

Schedule X—Single
If line 3 is:
Over—

$0
11,000
44,725
95,375
182,100
231,250
578,125

But not
over—

$11,000
44,725
95,375
182,100
231,250
578,125
and greater

Schedule Z—Head of household

The tax is:

of the
amount
over—

$0 + 10%
1,100 + 12%
5,147 + 22%
16,290 + 24%
37,104 + 32%
52,832 + 35%
174,238.25 + 37%

If line 3 is:
Over—

$0
11,000
44,725
95,375
182,100
231,250
578,125

$0
15,700
59,850
95,350
182,100
231,250
578,100

But not
over—

$15,700
59,850
95,350
182,100
231,250
578,100
and greater

The tax is:

$0 + 10%
1,570 + 12%
6,868 + 22%
14,678 + 24%
35,498 + 32%
51,226 + 35%
172,623.50 + 37%

of the
amount
over—

$0
15,700
59,850
95,350
182,100
231,250
578,100

Schedule Y-1—Married filing jointly or
Qualifying surviving spouse

Schedule Y-2—Married filing separately

If line 3 is:

If line 3 is:

Over—

$0
22,000
89,450
190,750
364,200
462,500
693,750

But not
over—

$22,000
89,450
190,750
364,200
462,500
693,750
and greater

The tax is:
$0 + 10%
2,200 + 12%
10,294 + 22%
32,580 + 24%
74,208 + 32%
105,664 + 35%
186,601.50 + 37%

of the
amount
over—

$0
22,000
89,450
190,750
364,200
462,500
693,750

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—

$0
11,000
44,725
95,375
182,100
231,250
346,875

But not
over—

$11,000
44,725
95,375
182,100
231,250
346,875
and greater

The tax is:
$0 + 10%
1,100 + 12%
5,147 + 22%
16,290 + 24%
37,104 + 32%
52,832 + 35%
93,300.75 + 37%

of the
amount
over—

$0
11,000
44,725
95,375
182,100
231,250
346,875

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.