|
Please fill out all sections of the application below. The 'Submit' button will appear at the bottom of the eForm when you have finished all relevant sections.
| Consent |
Reporting to work with impaired abilities; or the possession, consumption or distribution of drugs or alcohol on company premises and/or worksites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant or employee to agree to physical examination, polygraph and/or substance testing if required by the company. We are committed to operating a drug-free workplace. Violations of our drug and alcohol policy will result in dismissal. (With the exception of a drug authorized by a physician/primary health care provider for the employee's use while on the job, and whose performance is not noticeably impaired will not be considered in violation of this policy. Employees are responsible for forsaking the prescriber about any side effects that may influence performance
I Agree |
I understand that just as I am free to resign any time, the Employer reserves the right to terminate my employment at any time, with or without prior notice.
I Agree |
The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law
I Agree
|
I have received the Priority Home Care Services Standards of Conduct and acknowledge that I will comply with such standards as presented.
I Received the Standards of Conduct
|
I have reviewed the Employee Handbook, and Understand the Policies and Procedures of Priority Home Care Services.
Yes
|
I acknowledge that I have been provided with a copy of Priority Home Care Services Notice of Privacy Practices that provides a description of protected information uses and disclosures, and that I have had an opportunity to ask questions about anything that I did not understand.
I Acknowledge the above
|
I understand that this is an agreement bewveen Myself and the Consumer, which defines the conditions of employment. I am employed, as a participant in the Consumer Directed Program. I understand that I am directly responsible to the consumer, and not to Priority Home Care Services, Inc. I agree to work on the assigned days and times of my employment. I understand that I must contact my Consumer at least hN0 hours before my assigned work in case of illness or any emergency. I understand that I have to perform the tasks as listed on the care plan in a responsible, courteous, and prompt matter, and will be expected to respect your possessions, your lifestyle, and your home. I understand that I must provide the Consumer with at least Wvo weeks notice in case of extended time off or termination of my employment. understand that no confidential information is to be discussed or disclosed in any way without permission of the agency or the client.
I Agree
|
I understand that the State of New York Medicaid reimbursement regulations prohibit payment for home care services while the Consumer is hospitalized or admitted to a health care facility. Therefore, if a Consumer is hospitalized or admitted to a health care facility, the Personal Assistant will not be paid for the Consumer's inpatient stay. I agree to notify CHC of my Consumer's hospitalization immediately upon admission to the hospital/health care facility. I further understand that signing and submitting time sheets or clocking in and out during the Consumer's hospitalization or admission to a health care facility constitutes medicaid fraud. If I am paid erroneously by CHC during my consumer's admission to a health care facility,l understand that I am obligated to and agree to immediately return the full amount of over payment to CHC
I Agree
|
I understand that the State of New York Medicaid reimbursement regulations prohibit payment for home care services I AGREE THAT I AM NOT THE CONSUMERS PARENT, SPOUSE, OR POWER OF ATTORNEY, NOR DO I RESIDE WITH THE CONSUMER (excluding residing with the Consumer for live in cases).
I Agree
|
Signature of Applicant *:
Reset Signature
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Date *:
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Next |
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HEPATITIS INFORMATION ACKNOWLEDGEMENT ACCEPT OR DECLINATION STATEMENT
|
|
I have read and understand the information in the Hep-B packet. My signature below indicates acknowledgment of this information and my decision to either accept or decline the Hepatitis B vaccination
If I accept the vaccination, I understand that I will be given the opportunity to participate in the series, which includes injections at 0, 30, and 180 day intervals. I will comply with the administration procedure, and am aware of the adverse effects, contraindications, and complications that may occur due to the Hepatitis B Vaccination.
If I decline the vaccination, I either have received the vaccination prior, OR understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
|
| Form W-4 Department of the Treasury Internal Revenue Service |
Employee’s Withholding Allowance Certificate
▶ Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
▶ Give Form W-4 to your employer.
▶ Your withholding is subject to review by the IRS.
|
OMB No. 1545-0074
2020
|
| Step 1: Enter Personal Information |
|
| Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy |
| Step 4 (optional): Other Adjustments |
|
| Employers Only |
| Employer’s name and address
|
First date of employment
|
Employer identification number (EIN)
|
|
|
For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2020)
|
|
Form W-4 (2020)
General Instructions
Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4. Purpose. Complete Form
Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. If too little is withheld, you will generally owe tax when you file your tax return and may owe a penalty. If too much is withheld, you will generally be due a refund. Complete a new Form W-4 when changes to your personal or financial situation would change the entries on the form. For more information on withholding and when you must furnish a new Form W-4, see Pub. 505..
Exemption from withholding. You may claim exemption from withholding for 2020 if you meet both of the following conditions: you had no federal income tax liability in 2019 and you expect to have no federal income tax liability in 2020. You had no federal income tax liability in 2019 if (1) your total tax on line 16 on your 2019 Form 1040 or 1040-SR is zero (or less than the sum of lines 18a, 18b, and 18c), or (2) you were not required to file a return because your income was below the filing threshold for your correct filing status. If you claim exemption, you will have no income tax withheld from your paycheck and may owe taxes and penalties when you file your 2020 tax return. To claim exemption from withholding, certify that you meet both of the conditions above by writing “Exempt” on Form W-4 in the space below Step 4(c). Then, complete Steps 1a, 1b, and 5. Do not complete any other steps. You will need to submit a new Form W-4 by February 16, 2021.
Your privacy.If you prefer to limit information provided in Steps 2 through 4, use the online estimator, which will also increase accuracy
As an alternative to the estimator: if you have concerns with Step 2(c), you may choose Step 2(b); if you have concerns with Step 4(a), you may enter an additional amount you want withheld per pay period in Step 4(c). If this is the only job in your household, you may instead check the box in Step 2(c), which will increase your withholding and significantly reduce your paycheck (often by thousands of dollars over the year).
When to use the estimator. Consider using the estimator at www.irs.gov/W4App if you:
1. Expect to work only part of the year;
2. Have dividend or capital gain income, or are subject to additional taxes, such as the additional Medicare tax;
3. Have self-employment income (see below); or
4. Prefer the most accurate withholding for multiple job situations.
Self-employment. Generally, you will owe both income and self-employment taxes on any self-employment income you receive separate from the wages you receive as an employee. If you want to pay these taxes through withholding from your wages, use the estimator at www.irs.gov/W4App to figure the amount to have withheld.
Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. |
Specific Instructions
Step 1(c). Check your anticipated filing status. This will determine the standard deduction and tax rates used to compute your withholding.
Step 2. Use this step if you (1) have more than one job at the same time, or (2) are married filing jointly and you and your spouse both work.
Option (a) most accurately calculates the additional tax you need to have withheld, while option (b) does so with a little less accuracy.
If you (and your spouse) have a total of only two jobs, you may instead check the box in option (c). The box must also be checked on the Form W-4 for the other job. If the box is checked, the standard deduction and tax brackets will be cut in half for each job to calculate withholding. This option is roughly accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld, and this extra amount will be larger the greater the difference in pay is between the two jobs
Multiple jobs. Complete Steps 3 through 4(b) on only one Form W-4. Withholding will be most accurate if you do this on the Form W-4 for the highest paying job.
Step 3. Step 3 of Form W-4 provides instructions for determining the amount of the child tax credit and the credit for other dependents that you may be able to claim when you file your tax return. To qualify for the child tax credit, the child must be under age 17 as of December 31, must be your dependent who generally lives with you for more than half the year, and must have the required social security number. You may be able to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as an older child or a qualifying relative. For additional eligibility requirements for these credits, see Pub. 972, Child Tax Credit and Credit for Other Dependents. You can also include other tax credits in this step, such as education tax credits and the foreign tax credit. To do so, add an estimate of the amount for the year to your credits for dependents and enter the total amount in Step 3. Including these credits will increase your paycheck and reduce the amount of any refund you may receive when you file your tax return.
Step 4 (optional).
Step 4(a). Enter in this step the total of your other estimated income for the year, if any. You shouldn’t include income from any jobs or self-employment. If you complete Step 4(a), you likely won’t have to make estimated tax payments for that income. If you prefer to pay estimated tax rather than having tax on other income withheld from your paycheck, see Form 1040-ES, Estimated Tax for Individuals.
Step 4(b). Enter in this step the amount from the Deductions Worksheet, line 5, if you expect to claim deductions other than the basic standard deduction on your 2020 tax return and want to reduce your withholding to account for these deductions. This includes both itemized deductions and other deductions such as for student loan interest and IRAs. Step 4(c). Enter in this step any additional tax you want withheld from your pay each pay period, including any amounts from the Multiple Jobs Worksheet, line 4. Entering an amount here will reduce your paycheck and will either increase your refund or reduce any amount of tax that you owe. |
| Step 2(b)—Multiple Jobs Worksheet (Keep for your records.) |
If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.
Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional tables; or, you can use the online withholding estimator at www.irs.gov/W4App. |
| 1. Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have one job, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the “Lower Paying Job” column, find the value at the intersection of the two household salaries and enter that value on line 1. Then, skip to line 3 . . . . . . . . . . . . . . . . . . . . . |
1 $ |
| 2 Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and 2c below. Otherwise, skip to line 3. |
|
| a Find the amount from the appropriate table on page 4 using the annual wages from the highest paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job in the “Lower Paying Job” column. Find the value at the intersection of the two household salaries and enter that value on line 2a . . . . . . . . . . . . . . . . . . . . . . . |
2a. $ |
| b Add the annual wages of the two highest paying jobs from line 2a together and use the total as the wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount on line 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
2b. $ |
| c Add the amounts from lines 2a and 2b and enter the result on line 2c . . . . . . . . . . |
2c. $ |
| 3 Enter the number of pay periods per year for the highest paying job. For example, if that job pays weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. . . . . . |
3. $ |
| 4 Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional amount you want withheld) . . . . . . . . . . . . . . . . . . . . . . . . . |
4. $ |
| Step 4(b)—Deductions Worksheet (Keep for your records.) |
| 1 Enter an estimate of your 2020 itemized deductions (from Schedule A (Form 1040 or 1040-SR)). Such deductions may include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 10% of your income . . . . . . . . |
1 $ |
2 Enter: { • $24,800 if you’re married filing jointly or qualifying widow(er)
• $18,650 if you’re head of household
• $12,400 if you’re single or married filing separately } . . . . . . . . |
2 $ |
| 3 If line 1 is greater than line 2, subtract line 2 from line 1. If line 2 is greater than line 1, enter “-0-” . . |
3 $ |
| 4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other adjustments (from Schedule 1 (Form 1040 or 1040-SR)). See Pub. 505 for more information . . . |
4. $ |
| 5 Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 . . . . . . . . . . . |
5. $ |
| Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person with no other entries on the form; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. |
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. 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. |
| Married Filing Jointly or Qualifying Widow(er) |
| Higher Paying Job Annual Taxabl Wage & Salary |
Lower Paying Job Annual Taxable Wage & Salary |
| $0 - 9,999 |
$10,000 - 19,999 |
$20,000 - 29,999 |
$30,000 - 39,999 |
$40,000 - 49,999 |
$50,000 - 59,999 |
$60,000 - 69,999 |
$70,000 - 79,999 |
$80,000 - 89,999 |
$90,000 - 99,999 |
$100,000 - 109,999 |
$110,000 - 120,000 |
$0 - 9,999
$10,000 - 19,999
$20,000 - 29,999 |
$0
220
850 |
$220
1,220
1,900 |
$850
1,900
2,730 |
$900
2,100
2,930 |
$1,020
2,220
3,050 |
$1,020
2,220
3,050 |
$1,020
2,220
3,050 |
$1,020
2,220
3,240 |
$1,020
2,410
4,240 |
$1,210
3,410
5,240 |
$1,870
4,070
5,900 |
$1,870
4,070
5,900 |
$30,000 - 39,999
$40,000 - 49,999
$50,000 - 59,999 |
900
1,020
1,020 |
2,100
2,220
2,220 |
2,930
3,050
3,050 |
3,130
3,250
3,250 |
3,250
3,370
3,570 |
3,250
3,570
4,570 |
3,440
4,570
5,570 |
4,440
5,570
6,570 |
5,440
6,570
7,570 |
6,440
7,570
8,570 |
7,100
8,220
9,220 |
7,100
8,220
9,220 |
$60,000 - 69,999
$70,000 - 79,999
$80,000 - 99,999 |
1,020
1,020
1,060 |
2,220
2,220
3,260 |
3,050
3,240
5,090 |
3,440
4,440
6,290 |
4,570
5,570
7,420 |
5,570
6,570
8,420 |
6,570
7,570
9,420 |
7,570
8,570
10,420 |
8,570
9,570
11,420 |
9,570
10,570
12,420 |
10,220
11,220
13,260 |
10,220
11,240
13,460 |
$100,000 - 149,999
$150,000 - 239,999
$240,000 - 259,999 |
1,870
2,040
2,040 |
4,070
4,440
4,440 |
5,900
6,470
6,470 |
7,100
7,870
7,870 |
8,220
9,190
9,190 |
9,320
10,390
10,390 |
10,520
11,590
11,590 |
11,720
12,790
12,790 |
12,920
13,990
13,990 |
14,120
15,190
15,520 |
14,980
16,050
17,170 |
15,180
16,250
18,170 |
$260,000 - 279,999
$280,000 - 299,999
$300,000 - 319,999 |
2,040
2,040
2,040 |
4,440
4,440
4,440 |
6,470
6,470
6,470 |
7,870
7,870
8,200 |
9,190
9,190
10,320 |
10,390
10,720
12,320 |
11,590
12,720
14,320 |
13,120
14,720
16,320 |
15,120
16,720
18,320 |
17,120
18,720
20,320 |
18,770
20,370
21,970 |
19,770
21,370
22,970 |
$320,000 - 364,999
$365,000 - 524,999
$525,000 and over |
2,720
2,970
3,140 |
5,920
6,470
6,840 |
8,750
9,600
10,170 |
10,950
12,100
12,870 |
13,070
14,530
15,500 |
15,070
16,830
18,000 |
17,070
19,130
20,500 |
19,070
21,430
23,000 |
21,290
23,730
25,500 |
23,590
26,030
28,000 |
25,540
27,980
30,150 |
26,840
29,280
31,650 |
|
| Single or Married Filing Separately |
| Higher Paying Job Annual Taxabl Wage & Salary |
Lower Paying Job Annual Taxable Wage & Salary |
| $0 - 9,999 |
$10,000 - 19,999 |
$20,000 - 29,999 |
$30,000 - 39,999 |
$40,000 - 49,999 |
$50,000 - 59,999 |
$60,000 - 69,999 |
$70,000 - 79,999 |
$80,000 - 89,999 |
$90,000 - 99,999 |
$100,000 - 109,999 |
$110,000 - 120,000 |
$0 - 9,999
$10,000 - 19,999
$20,000 - 29,999 |
$460
940
1,020 |
$940
1,530
1,610 |
$1,020
1,610
2,130 |
$1,020
2,060
3,130 |
$1,470
3,060
4,130 |
$1,870
3,460
4,540 |
$1,870
3,460
4,540 |
$1,870
3,460
4,720 |
$1,870
3,640
4,920 |
$2,040
3,830
5,110 |
$2,040
3,830
5,110 |
$2,040
3,830
5,110 |
$30,000 - 39,999
$40,000 - 59,999
$60,000 - 79,999 |
1,020
1,870
1,870 |
2,060
3,460
3,460 |
3,130
4,540
4,690 |
4,130
5,540
5,890 |
5,130
6,690
7,090 |
5,540
7,290
7,690 |
5,720
7,490
7,690 |
5,920
7,690
8,090 |
6,120
7,890
8,290 |
6,310
8,080
8,480 |
6,310
8,080
9,260 |
6,310
8,080
10,060 |
$80,000 - 99,999
$100,000 - 124,999
$125,000 - 149,999 |
2,020
2,040
2,040 |
3,810
3,830
3,830 |
5,090
5,110
5,110 |
6,290
6,310
7,030 |
7,490
7,510
9,030 |
8,090
8,430
10,430 |
8,090
8,430
10,430 |
8,490
10,430
12,580 |
9,470
11,430
13,880 |
10,460
12,420
15,170 |
11,260
13,520
16,270 |
12,060
14,620
17,370 |
$150,000 - 174,999
$175,000 - 199,999
$200,000 - 249,999 |
2,360
2,720
2,970 |
4,950
5,310
5,860 |
7,030
7,540
8,240 |
9,030
9,840
10,540 |
11,030
12,140
12,840 |
12,730
13,840
14,540 |
14,030
15,140
15,840 |
15,330
16,440
17,140 |
16,630
17,740
18,440 |
17,920
19,030
19,730 |
19,020
20,130
20,830 |
20,120
21,230
21,930 |
$250,000 - 399,999
$400,000 - 449,999
$450,000 and over |
2,970
2,970
3,140 |
5,860
5,860
6,230 |
8,240
8,240
8,810 |
10,540
10,540
11,310 |
12,840
12,840
13,810 |
14,540
14,540
15,710 |
15,840
15,840
17,210 |
17,140
17,140
18,710 |
18,440
18,450
20,210 |
19,730
19,940
21,700 |
20,830
21,240
23,000 |
21,930
22,540
24,300 |
|
| Head of Household |
| Higher Paying Job Annual Taxabl Wage & Salary |
Lower Paying Job Annual Taxable Wage & Salary |
| $0 - 9,999 |
$10,000 - 19,999 |
$20,000 - 29,999 |
$30,000 - 39,999 |
$40,000 - 49,999 |
$50,000 - 59,999 |
$60,000 - 69,999 |
$70,000 - 79,999 |
$80,000 - 89,999 |
$90,000 - 99,999 |
$100,000 - 109,999 |
$110,000 - 120,000 |
$0 - 9,999
$10,000 - 19,999
$20,000 - 29,999 |
$0
830
930 |
$830
1,920
2,130 |
$930
2,130
2,350 |
$1,020
2,220
2,430 |
$1,020
2,220
2,900 |
$1,020
2,680
3,900 |
$1,480
3,680
4,900 |
$1,870
4,070
5,340 |
$1,870
4,130
5,540 |
$1,930
4,330
5,740 |
$2,040
4,440
5,850 |
$2,040
4,440
5,850 |
$30,000 - 39,999
$40,000 - 59,999
$60,000 - 79,999 |
1,020
1,020
1,870 |
2,220
2,530
4,070 |
2,430
3,750
5,310 |
2,980
4,830
6,600 |
3,980
5,860
7,800 |
4,980
7,060
9,000 |
6,040
8,260
10,200 |
6,630
8,850
10,780 |
6,830
9,050
10,980 |
7,030
9,250
11,180 |
7,140
9,360
11,580 |
7,140
9,360
12,380 |
$80,000 - 99,999
$100,000 - 124,999
$125,000 - 149,999 |
1,900
2,040
2,040 |
4,300
4,440
4,440 |
5,710
5,850
5,850 |
7,000
7,140
7,360 |
8,200
8,340
9,360 |
9,400
9,540
11,360 |
10,600
11,360
13,360 |
11,180
12,750
14,750 |
11,670
13,750
16,010 |
12,670
14,750
17,310 |
13,580
15,770
18,520 |
14,380
16,870
19,620 |
$150,000 - 174,999
$175,000 - 199,999
$200,000 - 249,999 |
2,040
2,720
2,970 |
5,060
5,920
6,470 |
7,280
8,130
8,990 |
9,360
10,480
11,370 |
11,360
12,780
13,670 |
13,480
15,080
15,970 |
15,780
17,380
18,270 |
17,460
19,070
19,960 |
18,760
20,370
21,260 |
20,060
21,670
22,560 |
21,270
22,880
23,770 |
22,370
23,980
24,870 |
$250,000 - 399,999
$400,000 - 449,999
$450,000 and over |
2,970
2,970
3,140 |
6,470
6,470
6,840 |
8,990
8,990
9,560 |
11,370
11,370
12,140 |
13,670
13,670
14,640 |
15,970
15,970
17,140 |
18,270
18,270
19,640 |
19,960
19,960
21,530 |
21,260
21,260
23,030
|
22,560
22,560
24,530 |
23,770
23,900
25,940 |
24,870
25,200
27,240 |
|
State of New York - Department of Taxation and Finance
Employee’s Withholding Allowance Certificate |
|
| Instructions |
Changes effective for 2020
Form IT-2104 has been revised for tax year 2020. The worksheet on page 4 and the charts beginning on page 5, used to compute withholding allowances or to enter an additional dollar amount on line(s) 3, 4, or 5, have been revised. If you previously filed a Form IT-2104 and used the worksheet or charts, you should complete a new 2020 Form IT-2104 and give it to your employer.
Who should file this form
This certificate, Form IT-2104, is completed by an employee and given to the employer to instruct the employer how much New York State (and New York City and Yonkers) tax to withhold from the employee’s pay. The more allowances claimed, the lower the amount of tax withheld. If the federal Form W-4 you most recently submitted to your employer was for tax year 2019 or earlier, and you do not file Form IT-2104, your employer may use the same number of allowances you claimed on your federal Form W-4. Due to differences in tax law, this may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers. For tax years 2020 or later, withholding allowances are no longer reported on federal Form W-4. Therefore, if you submit a federal Form W-4 to your employer for tax year 2020 or later, and you do not file Form IT-2104, your employer may use zero as your number of allowances. This may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers.
Complete Form IT-2104 each year and file it with your employer if the number of allowances you may claim is different from federal Form W-4 or has changed. Common reasons for completing a new Form IT-2104 each year include the following:
• You started a new job.
• You are no longer a dependent.
• Your individual circumstances may have changed (for example, you were married or have an additional child).
• You moved into or out of NYC or Yonkers.
• You itemize your deductions on your personal income tax return.
• You claim allowances for New York State credits.
• You owed tax or received a large refund when you filed your personal income tax return for the past year.
• Your wages have increased and you expect to earn $107,650 or more during the tax year.
• The total income of you and your spouse has increased to $107,650 or more for the tax year.
• You have significantly more or less income from other sources or from another job.
• You no longer qualify for exemption from withholding.
• You have been advised by the Internal Revenue Service that you are entitled to fewer allowances than claimed on your original federal Form W-4 (submitted to your employer for tax year 2019 or earlier), and the disallowed allowances were claimed on your original Form IT‑2104.
• You are a covered employee of an employer that has elected to participate in the Employer Compensation Expense Program.
• You made contributions to a New York Charitable Gifts Trust Fund (the Health Charitable Account or the Elementary and Secondary Education Account).
Exemption from withholding
You cannot use Form IT-2104 to claim exemption from withholding. To claim exemption from income tax withholding, you must file Form IT-2104-E, Certificate of Exemption from Withholding, with your employer. You must file a new certificate each year that you qualify for exemption. This exemption from withholding is allowable only if you had no New York income tax liability in the prior year, you expect none in the current year, and you are over 65 years of age, under 18, or a full-time student under 25. You may also claim exemption from withholding if you are a military spouse and meet the conditions set forth under the Servicemembers Civil Relief Act as amended by the Military Spouses Residency Relief Act and the Veterans Benefits and Transition Act. If you are a dependent who is under 18 or a full-time student, you may owe tax if your income is more than $3,100.
Withholding allowances
You may not claim a withholding allowance for yourself or, if married, your spouse. Claim the number of withholding allowances you compute in Part 1 and Part 5 of the worksheet on page 4. If you want more tax withheld, you may claim fewer allowances. If you claim more than 14 allowances, your employer must send a copy of your Form IT-2104 to the New York State Tax Department. You may then be asked to verify your allowances. If you arrive at negative allowances (less than zero) on lines 1 or 2 and your employer cannot accommodate negative allowances, enter 0 and see Additional dollar amount(s) below.
Income from sources other than wages – If you have more than $1,000 of income from sources other than wages (such as interest, dividends, or alimony received), reduce the number of allowances claimed on line 1 and line 2 (if applicable) of the IT-2104 certificate by one for each $1,000 of nonwage income. If you arrive at negative allowances (less than zero), see Withholding allowances above. You may also consider making estimated tax payments, especially if you have significant amounts of nonwage income. Estimated tax requires that payments be made by the employee directly to the Tax Department on a quarterly basis. For more information, see the instructions for Form IT‑2105, Estimated Tax Payment Voucher for Individuals, or see Need help? on page 7
Other credits (Worksheet line 14) – If you will be eligible to claim any credits other than the credits listed in the worksheet, such as an investment tax credit, you may claim additional allowances. Find your filing status and your New York adjusted gross income (NYAGI) in the chart below, and divide the amount of the expected credit by the number indicated. Enter the result (rounded to the nearest whole number) on line 14.
| Single and NYAGI is: |
Head of household and NYAGI is: |
Married and NYAGI is: |
Divide amount of expected credit by: |
Less than
$215,400 |
Less than
$269,300 |
Less than
$323,200 |
65 |
Between
$215,400 and $1,077,550 |
Between
$269,300 and $$1,616,450 |
Between
$323,200 and $2,155,350 |
68 |
Over
$1,077,550 |
Over
$1,616,450 |
Over
$2,155,350 |
88 |
|
Example: You are married and expect your New York adjusted gross income to be less than $323,200. In addition, you expect to receive a flow-through of an investment tax credit from the S corporation of which you are a shareholder. The investment tax credit will be $160. Divide the expected credit by 65. 160/65 = 2.4615. The additional withholding allowance(s) would be 2. Enter 2 on line 14.
Married couples with both spouses working – If you and your spouse both work, you should each file a separate IT‑2104 certificate with your respective employers. Your withholding will better match your total tax if the higher wage‑earning spouse claims all of the couple’s allowances and the lower wage‑earning spouse claims zero allowances. Do not claim more total allowances than you are entitled to. If your combined wages are:
• less than $107,650, you should each mark an X in the box Married, but withhold at higher single rate on the certificate front, and divide the total number of allowances that you compute on line 20 and line 35 (if applicable) between you and your working spouse.
• $107,650 or more, use the chart(s) in Part 6 and enter the additional withholding dollar amount on line 3.
Taxpayers with more than one job – If you have more than one job, file a separate IT-2104 certificate with each of your employers. Be sure to claim only the total number of allowances that you are entitled to. Your withholding will better match your total tax if you claim all of your allowances at your higher-paying job and zero allowances at the lower-paying job. In addition, to make sure that you have enough tax withheld, if you are a single taxpayer or head of household with two or more jobs, and your combined wages from all jobs are under $107,650, reduce the number of allowances by seven on line 1 and line 2 (if applicable) on the certificate you file with your higher‑paying job employer. If you arrive at negative allowances (less than zero), see Withholding allowances above
If you are a single or a head of household taxpayer, and your combined wages from all of your jobs are between $107,650 and $2,263,265, use the chart(s) in Part 7 and enter the additional withholding dollar amount from the chart on line 3.
If you are a married taxpayer, and your combined wages from all of your jobs are $107,650 or more, use the chart(s) in Part 6 and enter the additional withholding dollar amount from the chart on line 3 (Substitute the words Higher-paying job for Higher earner’s wages within the chart)
Dependents – If you are a dependent of another taxpayer and expect your income to exceed $3,100, you should reduce your withholding allowances by one for each $1,000 of income over $2,500. This will ensure that your employer withholds enough tax. Following the above instructions will help to ensure that you will not owe additional tax when you file your return.
Heads of households with only one job – If you will use the head-of-household filing status on your state income tax return, mark the Single or Head of household box on the front of the certificate. If you have only one job, you may also wish to claim two additional withholding allowances on line 15.
Additional dollar amount(s)
You may ask your employer to withhold an additional dollar amount each pay period by completing lines 3, 4, and 5 on Form IT‑2104. In most instances, if you compute a negative number of allowances and your employer cannot accommodate a negative number, for each negative allowance claimed you should have an additional $1.85 of tax withheld per week for New York State withholding on line 3, and an additional $0.80 of tax withheld per week for New York City withholding on line 4. Yonkers residents should use 16.75% (.1675) of the New York State amount for additional withholding for Yonkers on line 5.
Note: If you are requesting your employer to withhold an additional dollar amount on lines 3, 4, or 5 of this allowance certificate, the additional dollar amount, as determined by these instructions or by using the chart(s) in Part 6 or Part 7, is accurate for a weekly payroll. Therefore, if you are not paid on a weekly basis, you will need to adjust the dollar amount(s) that you compute. For example, if you are paid biweekly, you must double the dollar amount(s) computed
Avoid underwithholding
Form IT‑2104, together with your employer’s withholding tables, is designed to ensure that the correct amount of tax is withheld from your pay. If you fail to have enough tax withheld during the entire year, you may owe a large tax liability when you file your return. The Tax Department must assess interest and may impose penalties in certain situations in addition to the tax liability. Even if you do not file a return, we may determine that you owe personal income tax, and we may assess interest and penalties on the amount of tax that you should have paid during the year.
Employers Box A – If you are required to submit a copy of an employee’s Form IT-2104 to the Tax Department because the employee claimed more than 14 allowances, mark an X in box A and send a copy of Form IT-2104 to: NYS Tax Department, Income Tax Audit Administrator, Withholding Certificate Coordinator, W A Harriman Campus, Albany NY 12227-0865. If the employee is also a new hire or rehire, see Box B instructions. See Publication 55, Designated Private Delivery Services, if not using U.S. Mail.
Due dates for sending certificates received from employees claiming more than 14 allowances are:
| Quarter |
Due date |
Quarter |
Due date |
| January – March |
April 30 |
July – September |
October 31 |
| April – June |
July 31 |
October – December |
January 31 |
Box B – If you are submitting a copy of this form to comply with New York State’s New Hire Reporting Program, mark an X in box B. Enter the first day any services are performed for which the employee will be paid wages, commissions, tips and any other type of compensation. For services based solely on commissions, this is the first day an employee working for commissions is eligible to earn commissions. Also, mark an X in the Yes or No box indicating if dependent health insurance benefits are available to this employee. If Yes , enter the date the employee qualifies for coverage. Mail the completed form, within 20 days of hiring, to: NYS Tax Department, New Hire Notification, PO Box 15119, Albany NY 12212-5119. To report newly-hired or rehired employees online instead of submitting this form, go to https://www.nynewhire.com |
Worksheet
See the instructions before completing this worksheet. |
| Part 1 – Complete this part to compute your withholding allowances for New York State and Yonkers (line 1) |
6 Enter the number of dependents that you will claim on your state return (do not include yourself or, if married, your spouse) ..... For lines 7, 8, and 9, enter 1 for each credit you expect to claim on your state return.
7 College tuition credit ..................................................................................................................................................................
8 New York State household credit ...............................................................................................................................................
9 Real property tax credit ..............................................................................................................................................................
For lines 10, 11, and 12, enter 3 for each credit you expect to claim on your state return.
10 Child and dependent care credit ............................................................................................................................................... |
6. |
| 7. |
| 8 |
| 9 |
| 10 |
| 11 Earned income credit ................................................................................................................................................................ |
11 |
| 12 Empire State child credit ........................................................................................................................................................... |
12 |
| 13 New York City school tax credit: If you expect to be a resident of New York City for any part of the tax year, enter 2............. |
13 |
| 14 Other credits (see instructions) ..................................................................................................................................................... |
14 |
| 15 Head of household status and only one job (enter 2 if the situation applies) .................................................................................. |
15 |
| 16 Enter an estimate of your federal adjustments to income, such as deductible IRA contributions you will make for the tax year. Total estimate $ . Divide this estimate by $1,000. Drop any fraction and enter the number ...... |
16 |
| 17 If you expect to be a covered employee of an employer who elected to pay the employer compensation expense tax in 2020, complete Part 3 below and enter the number from line 29 .......................................................................................... |
17 |
| 18 If you made contributions in 2019 to a New York Charitable Gifts Trust Fund (the Health Charitable Account or the Elementary and Secondary Education Account), complete Part 4 below and enter the amount from line 32 ...................... |
18 |
| 19 If you expect to itemize deductions on your state tax return, complete Part 2 below and enter the number from line 24. All others enter 0 ................................................................................................................................................................... |
19 |
| 20 Add lines 6 through 19. Enter the result here and on line 1. If you have more than one job, or if you and your spouse both work, see instructions for Taxpayers with more than one job or Married couples with both spouses working. ..................... |
20 |
| Part 2 – Complete this part only if you expect to itemize deductions on your state return. |
| 21 Enter your estimated NY itemized deductions for the tax year (see Form IT-196 and its instructions; enter the amount from line 49) |
21 |
| 22 Based on your federal filing status, enter the applicable amount from the table below ............................................................ |
22 |
| Standard deduction table |
| Single (cannot be claimed as a dependent) .... |
$ 8,000 |
Qualifying widow(er) ....................................... |
$16,050 |
| Single (can be claimed as a dependent) ..... |
$ 3,100 |
Married filing jointly .......................................... |
$16,050 |
| Head of household ......................................... |
$11,200 |
Married filing separate returns ......................... |
$ 8,000 |
|
|
| 23 Subtract line 22 from line 21 (if line 22 is larger than line 21, enter 0 here and on line 19 above) ........................................................ |
23 |
| 24 Divide line 23 by $1,000. Drop any fraction and enter the result here and on line 19 above .................................................... |
24 |
| Part 3 – Complete this part if you expect to be a covered employee of an employer that has elected to participate in the Employer Compensation Expense Program (line 17). |
| 25 Expected annual wages and compensation from electing employer in 2020 ........................................................................... |
25 |
| 26 Line 25 minus $40,000 (if zero or less, stop) ........................................................................................................................... |
26 |
| 27 Line 26 multiplied by .03 ........................................................................................................................................................... |
27 |
| 28 Line 27 multiplied by .935 ......................................................................................................................................................... |
28 |
| 29 Divide line 28 by 65. Drop any fraction and enter the result here and on line 17 above ........................................................... |
29 |
| Part 4 – Complete this part if you made contributions in 2019 to the Health Charitable Account or the Elementary and Secondary Education Account (line 18). |
| 30 Contributions to these funds in 2019 ........................................................................................................................................ |
30 |
| 31 Multiply line 30 by 85% (.85) ..................................................................................................................................................... |
31 |
| 32 Divide line 31 by 60. Drop any fraction and enter the result here and on line 18 above ........................................................... |
32 |
| Part 5 – Complete this part to compute your withholding allowances for New York City (line 2). |
| 33 Enter the amount from line 6 above .......................................................................................................................................... |
33 |
| 34 Add lines 15 through 19 above and enter total here ................................................................................................................. |
34 |
| 35 Add lines 33 and 34. Enter the result here and on line 2 .......................................................................................................... |
35 |
Part 6 – These charts are only for married couples with both spouses working or married couples with one spouse working more than one job, and whose combined wages are between $107,650 and $2,263,265.
Enter the additional withholding dollar amount on line 3.
The additional dollar amount, as shown below, is accurate for a weekly payroll. If you are not paid on a weekly basis, you will need to adjust these dollar amount(s). For example, if you are paid biweekly, you must double the dollar amount(s) computed. |
|
|
|
|
|
Combined wages between $107,650 and $538,749
|
|
|
|
Higher earner’s wages
|
$107,650
|
$129,250
|
$150,750
|
$172,300
|
$193,850
|
$236,950
|
$280,100
|
$323,200
|
$377,100
|
$430,950
|
$484,900
|
|
$129,249
|
$150,749
|
$172,299
|
$193,849
|
$236,949
|
$280,099
|
$323,199
|
$377,099
|
$430,949
|
$484,899
|
$538,749
|
|
|
|
|
$53,800
|
$75,299
|
$13
|
$19
|
|
|
|
|
|
|
|
|
|
|
$75,300
|
$96,799
|
$12
|
$20
|
$28
|
$32
|
|
|
|
|
|
|
|
|
$96,800
|
$118,399
|
$8
|
$17
|
$24
|
$32
|
$39
|
|
|
|
|
|
|
|
$118,400
|
$129,249
|
$2
|
$11
|
$19
|
$26
|
$36
|
$33
|
|
|
|
|
|
|
$129,250
|
$139,999
|
|
$4
|
$15
|
$22
|
$33
|
$30
|
|
|
|
|
|
|
$140,000
|
$150,749
|
|
$2
|
$11
|
$18
|
$29
|
$30
|
$25
|
|
|
|
|
|
$150,750
|
$161,549
|
|
|
$4
|
$15
|
$25
|
$30
|
$22
|
|
|
|
|
|
$161,550
|
$172,499
|
|
|
$2
|
$11
|
$22
|
$28
|
$22
|
$19
|
|
|
|
|
$172,500
|
$193,849
|
|
|
|
$4
|
$16
|
$23
|
$22
|
$29
|
$30
|
|
|
|
$193,850
|
$236,949
|
|
|
|
|
$6
|
$12
|
$18
|
$30
|
$36
|
$31
|
|
|
$236,950
|
$280,099
|
|
|
|
|
|
$6
|
$12
|
$36
|
$45
|
$39
|
$41
|
|
$280,100
|
$323,199
|
|
|
|
|
|
|
$6
|
$30
|
$53
|
$47
|
$41
|
|
$323,200
|
$377,099
|
|
|
|
|
|
|
|
$15
|
$31
|
$40
|
$34
|
|
$377,100
|
$430,949
|
|
|
|
|
|
|
|
|
$8
|
$18
|
$27
|
|
$430,950
|
$484,899
|
|
|
|
|
|
|
|
|
|
$8
|
$18
|
|
$484,900
|
$538,749
|
|
|
|
|
|
|
|
|
|
|
$8
|
|
|
|
|
|
|
Combined wages between $538,750 and $1,185,399
|
|
|
|
Higher earner’s
wages
|
$538,750
|
$592,650
|
$646,500
|
$700,400
|
$754,300
|
$808,200
|
$862,050
|
$915,950
|
$969,900
|
$1,023,750
|
$1,077,550
|
$1,131,500
|
|
$592,649
|
$646,499
|
$700,399
|
$754,299
|
$808,199
|
$862,049
|
$915,949
|
$969,899
|
$1,023,749
|
$1,077,549
|
$1,131,499
|
$1,185,399
|
|
|
|
|
$236,950
|
$280,099
|
$28
|
|
|
|
|
|
|
|
|
|
|
|
|
$280,100
|
$323,199
|
$45
|
$22
|
|
|
|
|
|
|
|
|
|
|
|
$323,200
|
$377,099
|
$28
|
$33
|
$37
|
$22
|
|
|
|
|
|
|
|
|
|
$377,100
|
$430,949
|
$21
|
$16
|
$20
|
$25
|
$5
|
$5
|
|
|
|
|
|
|
|
$430,950
|
$484,899
|
$27
|
$21
|
$16
|
$20
|
$25
|
$5
|
$5
|
$5
|
|
|
|
|
|
$484,900
|
$538,749
|
$18
|
$27
|
$21
|
$16
|
$20
|
$25
|
$5
|
$5
|
$5
|
$5
|
|
|
|
$538,750
|
$592,649
|
$8
|
$18
|
$27
|
$21
|
$16
|
$20
|
$25
|
$5
|
$5
|
$5
|
$3
|
$2
|
|
$592,650
|
$646,499
|
|
$8
|
$18
|
$27
|
$21
|
$16
|
$20
|
$25
|
$5
|
$5
|
$3
|
$2
|
|
$646,500
|
$700,399
|
|
|
$8
|
$18
|
$27
|
$21
|
$16
|
$20
|
$25
|
$5
|
$3
|
$2
|
|
$700,400
|
$754,299
|
|
|
|
$8
|
$18
|
$27
|
$21
|
$16
|
$20
|
$25
|
$3
|
$2
|
|
$754,300
|
$808,199
|
|
|
|
|
$8
|
$18
|
$27
|
$21
|
$16
|
$20
|
$26
|
$2
|
|
$808,200
|
$862,049
|
|
|
|
|
|
$8
|
$18
|
$27
|
$21
|
$16
|
$22
|
$29
|
|
$862,050
|
$915,949
|
|
|
|
|
|
|
$8
|
$18
|
$27
|
$21
|
$17
|
$25
|
|
$915,950
|
$969,899
|
|
|
|
|
|
|
|
$8
|
$18
|
$27
|
$22
|
$20
|
|
$969,900
|
$1,023,749
|
|
|
|
|
|
|
|
|
$8
|
$18
|
$29
|
$26
|
|
$1,023,750
|
$1,077,549
|
|
|
|
|
|
|
|
|
|
$8
|
$20
|
$32
|
|
$1,077,550
|
$1,131,499
|
|
|
|
|
|
|
|
|
|
|
$9
|
$21
|
|
$1,131,500
|
$1,185,399
|
|
|
|
|
|
|
|
|
|
|
|
$9
|
|
|
|
|
Combined wages between $1,185,400 and $1,724,299
|
|
|
Higher earner’s wages
|
$1,185,400
|
$1,239,250
|
$1,293,200
|
$1,347,050
|
$1,400,950
|
$1,454,850
|
$1,508,700
|
$1,562,550
|
$1,616,450
|
$1,670,400
|
|
$1,239,249
|
$1,293,199
|
$1,347,049
|
$1,400,949
|
$1,454,849
|
$1,508,699
|
$1,562,549
|
$1,616,449
|
$1,670,399
|
$1,724,299
|
|
$592,650
|
$646,499
|
$5
|
$8
|
|
|
|
|
|
|
|
|
|
$646,500
|
$700,399
|
$5
|
$8
|
$11
|
$14
|
|
|
|
|
|
|
|
$700,400
|
$754,299
|
$5
|
$8
|
$11
|
$14
|
$18
|
$21
|
|
|
|
|
|
$754,300
|
$808,199
|
$5
|
$8
|
$11
|
$14
|
$18
|
$21
|
$24
|
$27
|
|
|
|
$808,200
|
$862,049
|
$5
|
$8
|
$11
|
$14
|
$18
|
$21
|
$24
|
$27
|
$30
|
$33
|
|
$862,050
|
$915,949
|
$32
|
$8
|
$11
|
$14
|
$18
|
$21
|
$24
|
$27
|
$30
|
$33
|
|
$915,950
|
$969,899
|
$28
|
$36
|
$11
|
$14
|
$18
|
$21
|
$24
|
$27
|
$30
|
$33
|
|
$969,900
|
$1,023,749
|
$23
|
$31
|
$39
|
$14
|
$18
|
$21
|
$24
|
$27
|
$30
|
$33
|
|
$1,023,750
|
$1,077,549
|
$29
|
$26
|
$34
|
$42
|
$18
|
$21
|
$24
|
$27
|
$30
|
$33
|
|
$1,077,550
|
$1,131,499
|
$33
|
$30
|
$28
|
$36
|
$43
|
$19
|
$22
|
$25
|
$28
|
$32
|
|
$1,131,500
|
$1,185,399
|
$21
|
$33
|
$30
|
$28
|
$36
|
$43
|
$19
|
$22
|
$25
|
$28
|
|
$1,185,400
|
$1,239,249
|
$9
|
$21
|
$33
|
$30
|
$28
|
$36
|
$43
|
$19
|
$22
|
$25
|
|
$1,239,250
|
$1,293,199
|
|
$9
|
$21
|
$33
|
$30
|
$28
|
$36
|
$43
|
$19
|
$22
|
|
$1,293,200
|
$1,347,049
|
|
|
$9
|
$21
|
$33
|
$30
|
$28
|
$36
|
$43
|
$19
|
|
$1,347,050
|
$1,400,949
|
|
|
|
$9
|
$21
|
$33
|
$30
|
$28
|
$36
|
$43
|
|
$1,400,950
|
$1,454,849
|
|
|
|
|
$9
|
$21
|
$33
|
$30
|
$28
|
$36
|
|
$1,454,850
|
$1,508,699
|
|
|
|
|
|
$9
|
$21
|
$33
|
$30
|
$28
|
|
$1,508,700
|
$1,562,549
|
|
|
|
|
|
|
$9
|
$21
|
$33
|
$30
|
|
$1,562,550
|
$1,616,449
|
|
|
|
|
|
|
|
$9
|
$21
|
$33
|
|
$1,616,450
|
$1,670,399
|
|
|
|
|
|
|
|
|
$9
|
$21
|
|
$1,670,400
|
$1,724,299
|
|
|
|
|
|
|
|
|
|
$9
|
|
|
|
|
Combined wages between $1,724,300 and $2,263,265
|
|
|
Higher earner’s wages
|
$1,724,300
|
$1,778,150
|
$1,832,050
|
$1,885,950
|
$1,939,800
|
$1,993,700
|
$2,047,600
|
$2,101,500
|
$2,155,350
|
$2,209,300
|
|
$1,778,149
|
$1,832,049
|
$1,885,949
|
$1,939,799
|
$1,993,699
|
$2,047,599
|
$2,101,499
|
$2,155,349
|
$2,209,299
|
$2,263,265
|
|
$862,050
|
$915,949
|
$36
|
$39
|
|
|
|
|
|
|
|
|
|
$915,950
|
$969,899
|
$36
|
$39
|
$42
|
$46
|
|
|
|
|
|
|
|
$969,900
|
$1,023,749
|
$36
|
$39
|
$42
|
$46
|
$49
|
$52
|
|
|
|
|
|
$1,023,750
|
$1,077,549
|
$36
|
$39
|
$42
|
$46
|
$49
|
$52
|
$55
|
$58
|
|
|
|
$1,077,550
|
$1,131,499
|
$35
|
$38
|
$41
|
$44
|
$47
|
$50
|
$53
|
$56
|
$490
|
$906
|
|
$1,131,500
|
$1,185,399
|
$32
|
$35
|
$38
|
$41
|
$44
|
$47
|
$50
|
$53
|
$487
|
$906
|
|
$1,185,400
|
$1,239,249
|
$28
|
$32
|
$35
|
$38
|
$41
|
$44
|
$47
|
$50
|
$484
|
$903
|
|
$1,239,250
|
$1,293,199
|
$25
|
$28
|
$32
|
$35
|
$38
|
$41
|
$44
|
$47
|
$481
|
$900
|
|
$1,293,200
|
$1,347,049
|
$22
|
$25
|
$28
|
$32
|
$35
|
$38
|
$41
|
$44
|
$477
|
$897
|
|
$1,347,050
|
$1,400,949
|
$19
|
$22
|
$25
|
$28
|
$32
|
$35
|
$38
|
$41
|
$474
|
$894
|
|
$1,400,950
|
$1,454,849
|
$43
|
$19
|
$22
|
$25
|
$28
|
$32
|
$35
|
$38
|
$471
|
$891
|
|
$1,454,850
|
$1,508,699
|
$36
|
$43
|
$19
|
$22
|
$25
|
$28
|
$32
|
$35
|
$468
|
$888
|
|
$1,508,700
|
$1,562,549
|
$28
|
$36
|
$43
|
$19
|
$22
|
$25
|
$28
|
$32
|
$465
|
$885
|
|
$1,562,550
|
$1,616,449
|
$30
|
$28
|
$36
|
$43
|
$19
|
$22
|
$25
|
$28
|
$462
|
$881
|
|
$1,616,450
|
$1,670,399
|
$33
|
$30
|
$28
|
$36
|
$43
|
$19
|
$22
|
$25
|
$459
|
$878
|
|
$1,670,400
|
$1,724,299
|
$21
|
$33
|
$30
|
$28
|
$36
|
$43
|
$19
|
$22
|
$456
|
$875
|
|
$1,724,300
|
$1,778,149
|
$9
|
$21
|
$33
|
$30
|
$28
|
$36
|
$43
|
$19
|
$453
|
$872
|
|
$1,778,150
|
$1,832,049
|
|
$9
|
$21
|
$33
|
$30
|
$28
|
$36
|
$43
|
$449
|
$869
|
|
$1,832,050
|
$1,885,949
|
|
|
$9
|
$21
|
$33
|
$30
|
$28
|
$36
|
$474
|
$866
|
|
$1,885,950
|
$1,939,799
|
|
|
|
$9
|
$21
|
$33
|
$30
|
$28
|
$466
|
$890
|
|
$1,939,800
|
$1,993,699
|
|
|
|
|
$9
|
$21
|
$33
|
$30
|
$458
|
$882
|
|
$1,993,700
|
$2,047,599
|
|
|
|
|
|
$9
|
$21
|
$33
|
$461
|
$875
|
|
$2,047,600
|
$2,101,499
|
|
|
|
|
|
|
$9
|
$21
|
$464
|
$877
|
|
$2,101,500
|
$2,155,349
|
|
|
|
|
|
|
|
$9
|
$451
|
$880
|
|
$2,155,350
|
$2,209,299
|
|
|
|
|
|
|
|
|
$235
|
$438
|
|
$2,209,300
|
$2,263,265
|
|
|
|
|
|
|
|
|
|
$14
|
Note: These charts do not account for additional withholding in the following instances
-
a married couple with both spouses working, where one spouse’s wages are more than $1,131,632 but less than $2,263,265, and the other spouse’s wages are also more than $1,131,632 but less than $2,263,265;
-
married taxpayers with only one spouse working, and that spouse works more than one job, with wages from each job under $2,263,265, but combined wages from all jobs is over $2,263,265.
If you are in one of these situations and you would like to request an additional dollar amount of withholding from your wages, please contact the Tax Department for assistance (see Need help? on page 7).
Part 7 – These charts are only for single taxpayers and head of household taxpayers with more than one job, and whose combined wages are between $107,650 and $2,263,265.
Enter the additional withholding dollar amount on line 3.
The additional dollar amount, as shown below, is accurate for a weekly payroll. If you are not paid on a weekly basis, you will need to adjust these dollar amount(s). For example, if you are paid biweekly, you must double the dollar amount(s) computed.
|
|
|
|
|
Combined wages between $107,650 and $538,749
|
|
|
|
Higher wage
|
$107,650
|
$129,250
|
$150,750
|
$172,300
|
$193,850
|
$236,950
|
$280,100
|
$323,200
|
$377,100
|
$430,950
|
$484,900
|
|
$129,249
|
$150,749
|
$172,299
|
$193,849
|
$236,949
|
$280,099
|
$323,199
|
$377,099
|
$430,949
|
$484,899
|
$538,749
|
|
|
|
|
$53,800
|
$75,299
|
$13
|
$18
|
|
|
|
|
|
|
|
|
|
|
$75,300
|
$96,799
|
$12
|
$20
|
$27
|
$26
|
|
|
|
|
|
|
|
|
$96,800
|
$118,399
|
$8
|
$17
|
$24
|
$27
|
$28
|
|
|
|
|
|
|
|
$118,400
|
$129,249
|
$2
|
$11
|
$18
|
$21
|
$26
|
$35
|
|
|
|
|
|
|
$129,250
|
$139,999
|
|
$4
|
$14
|
$17
|
$22
|
$39
|
|
|
|
|
|
|
$140,000
|
$150,749
|
|
$2
|
$10
|
$13
|
$19
|
$39
|
$38
|
|
|
|
|
|
$150,750
|
$161,549
|
|
|
$3
|
$10
|
$15
|
$38
|
$36
|
|
|
|
|
|
$161,550
|
$172,499
|
|
|
$1
|
$7
|
$13
|
$38
|
$38
|
$36
|
|
|
|
|
$172,500
|
$193,849
|
|
|
|
$3
|
$10
|
$36
|
$42
|
$38
|
$37
|
|
|
|
$193,850
|
$236,949
|
|
|
|
|
$11
|
$31
|
$44
|
$42
|
$42
|
$25
|
|
|
$236,950
|
$280,099
|
|
|
|
|
|
$9
|
$18
|
$29
|
$25
|
$28
|
$15
|
|
$280,100
|
$323,199
|
|
|
|
|
|
|
$7
|
$17
|
$27
|
$22
|
$26
|
|
$323,200
|
$377,099
|
|
|
|
|
|
|
|
$8
|
$18
|
$27
|
$22
|
|
$377,100
|
$430,949
|
|
|
|
|
|
|
|
|
$8
|
$18
|
$27
|
|
$430,950
|
$484,899
|
|
|
|
|
|
|
|
|
|
$8
|
$18
|
|
$484,900
|
$538,749
|
|
|
|
|
|
|
|
|
|
|
$8
|
|
|
|
|
|
|
Combined wages between $538,750 and $1,185,399
|
|
|
|
|
Higher wage
|
$538,750
|
$592,650
|
$646,500
|
$700,400
|
$754,300
|
$808,200
|
$862,050
|
$915,950
|
$969,900
|
$1,023,750
|
$1,077,550
|
$1,131,500
|
|
$592,649
|
$646,499
|
$700,399
|
$754,299
|
$808,199
|
$862,049
|
$915,949
|
$969,899
|
$1,023,749
|
$1,077,549
|
$1,131,499
|
$1,185,399
|
|
|
|
|
$236,950
|
$280,099
|
$9
|
|
|
|
|
|
|
|
|
|
|
|
|
$280,100
|
$323,199
|
$9
|
$8
|
|
|
|
|
|
|
|
|
|
|
|
$323,200
|
$377,099
|
$26
|
$8
|
$8
|
$8
|
|
|
|
|
|
|
|
|
|
$377,100
|
$430,949
|
$22
|
$26
|
$8
|
$8
|
$8
|
$8
|
|
|
|
|
|
|
|
$430,950
|
$484,899
|
$27
|
$22
|
$26
|
$8
|
$8
|
$8
|
$8
|
$8
|
|
|
|
|
|
$484,900
|
$538,749
|
$18
|
$27
|
$22
|
$26
|
$8
|
$8
|
$8
|
$8
|
$8
|
$8
|
|
|
|
$538,750
|
$592,649
|
$8
|
$18
|
$27
|
$22
|
$26
|
$8
|
$8
|
$8
|
$8
|
$8
|
$236
|
$451
|
|
$592,650
|
$646,499
|
|
$8
|
$18
|
$27
|
$22
|
$26
|
$8
|
$8
|
$8
|
$8
|
$236
|
$451
|
|
$646,500
|
$700,399
|
|
|
$8
|
$18
|
$27
|
$22
|
$26
|
$8
|
$8
|
$8
|
$236
|
$451
|
|
$700,400
|
$754,299
|
|
|
|
$8
|
$18
|
$27
|
$22
|
$26
|
$8
|
$8
|
$236
|
$451
|
|
$754,300
|
$808,199
|
|
|
|
|
$8
|
$18
|
$27
|
$22
|
$26
|
$8
|
$236
|
$451
|
|
$808,200
|
$862,049
|
|
|
|
|
|
$8
|
$18
|
$27
|
$22
|
$26
|
$236
|
$451
|
|
$862,050
|
$915,949
|
|
|
|
|
|
|
$8
|
$18
|
$27
|
$22
|
$254
|
$451
|
|
$915,950
|
$969,899
|
|
|
|
|
|
|
|
$8
|
$18
|
$27
|
$250
|
$470
|
|
$969,900
|
$1,023,749
|
|
|
|
|
|
|
|
|
$8
|
$18
|
$255
|
$465
|
|
$1,023,750
|
$1,077,549
|
|
|
|
|
|
|
|
|
|
$8
|
$246
|
$471
|
|
$1,077,550
|
$1,131,499
|
|
|
|
|
|
|
|
|
|
|
$123
|
$233
|
|
$1,131,500
|
$1,185,399
|
|
|
|
|
|
|
|
|
|
|
|
$14
|
|
|
|
|
Combined wages between $1,185,400 and $1,724,299
|
|
|
Higher wage
|
$1,185,400
|
$1,239,250
|
$1,293,200
|
$1,347,050
|
$1,400,950
|
$1,454,850
|
$1,508,700
|
$1,562,550
|
$1,616,450
|
$1,670,400
|
|
$1,239,249
|
$1,293,199
|
$1,347,049
|
$1,400,949
|
$1,454,849
|
$1,508,699
|
$1,562,549
|
$1,616,449
|
$1,670,399
|
$1,724,299
|
|
|
|
|
$592,650
|
$646,499
|
$475
|
$498
|
|
|
|
|
|
|
|
|
|
$646,500
|
$700,399
|
$475
|
$498
|
$522
|
$546
|
|
|
|
|
|
|
|
$700,400
|
$754,299
|
$475
|
$498
|
$522
|
$546
|
$569
|
$593
|
|
|
|
|
|
$754,300
|
$808,199
|
$475
|
$498
|
$522
|
$546
|
$569
|
$593
|
$616
|
$640
|
|
|
|
$808,200
|
$862,049
|
$475
|
$498
|
$522
|
$546
|
$569
|
$593
|
$616
|
$640
|
$663
|
$687
|
|
$862,050
|
$915,949
|
$475
|
$498
|
$522
|
$546
|
$569
|
$593
|
$616
|
$640
|
$663
|
$687
|
|
$915,950
|
$969,899
|
$475
|
$498
|
$522
|
$546
|
$569
|
$593
|
$616
|
$640
|
$663
|
$687
|
|
$969,900
|
$1,023,749
|
$493
|
$498
|
$522
|
$546
|
$569
|
$593
|
$616
|
$640
|
$663
|
$687
|
|
$1,023,750
|
$1,077,549
|
$489
|
$517
|
$522
|
$546
|
$569
|
$593
|
$616
|
$640
|
$663
|
$687
|
|
$1,077,550
|
$1,131,499
|
$266
|
$284
|
$312
|
$318
|
$341
|
$365
|
$388
|
$412
|
$435
|
$459
|
|
$1,131,500
|
$1,185,399
|
$42
|
$74
|
$92
|
$120
|
$126
|
$149
|
$173
|
$196
|
$220
|
$243
|
|
$1,185,400
|
$1,239,249
|
$14
|
$42
|
$74
|
$92
|
$120
|
$126
|
$149
|
$173
|
$196
|
$220
|
|
$1,239,250
|
$1,293,199
|
|
$14
|
$42
|
$74
|
$92
|
$120
|
$126
|
$149
|
$173
|
$196
|
|
$1,293,200
|
$1,347,049
|
|
|
$14
|
$42
|
$74
|
$92
|
$120
|
$126
|
$149
|
$173
|
|
$1,347,050
|
$1,400,949
|
|
|
|
$14
|
$42
|
$74
|
$92
|
$120
|
$126
|
$149
|
|
$1,400,950
|
$1,454,849
|
|
|
|
|
$14
|
$42
|
$74
|
$92
|
$120
|
$126
|
|
$1,454,850
|
$1,508,699
|
|
|
|
|
|
$14
|
$42
|
$74
|
$92
|
$120
|
|
$1,508,700
|
$1,562,549
|
|
|
|
|
|
|
$14
|
$42
|
$74
|
$92
|
|
$1,562,550
|
$1,616,449
|
|
|
|
|
|
|
|
$14
|
$42
|
$74
|
|
$1,616,450
|
$1,670,399
|
|
|
|
|
|
|
|
|
$14
|
$42
|
|
$1,670,400
|
$1,724,299
|
|
|
|
|
|
|
|
|
|
$14
|
|
|
|
|
Combined wages between $1,724,300 and $2,263,265
|
|
|
Higher wage
|
$1,724,300
|
$1,778,150
|
$1,832,050
|
$1,885,950
|
$1,939,800
|
$1,993,700
|
$2,047,600
|
$2,101,500
|
$2,155,350
|
$2,209,300
|
|
$1,778,149
|
$1,832,049
|
$1,885,949
|
$1,939,799
|
$1,993,699
|
$2,047,599
|
$2,101,499
|
$2,155,349
|
$2,209,299
|
$2,263,265
|
|
|
|
|
$862,050
|
$915,949
|
$710
|
$734
|
|
|
|
|
|
|
|
|
|
$915,950
|
$969,899
|
$710
|
$734
|
$757
|
$781
|
|
|
|
|
|
|
|
$969,900
|
$1,023,749
|
$710
|
$734
|
$757
|
$781
|
$804
|
$828
|
|
|
|
|
|
$1,023,750
|
$1,077,549
|
$710
|
$734
|
$757
|
$781
|
$804
|
$828
|
$851
|
$875
|
|
|
|
$1,077,550
|
$1,131,499
|
$482
|
$506
|
$529
|
$553
|
$576
|
$600
|
$623
|
$647
|
$670
|
$262
|
|
$1,131,500
|
$1,185,399
|
$267
|
$290
|
$314
|
$337
|
$361
|
$384
|
$408
|
$431
|
$455
|
$478
|
|
$1,185,400
|
$1,239,249
|
$243
|
$267
|
$290
|
$314
|
$337
|
$361
|
$384
|
$408
|
$431
|
$455
|
|
$1,239,250
|
$1,293,199
|
$220
|
$243
|
$267
|
$290
|
$314
|
$337
|
$361
|
$384
|
$408
|
$431
|
|
$1,293,200
|
$1,347,049
|
$196
|
$220
|
$243
|
$267
|
$290
|
$314
|
$337
|
$361
|
$384
|
$408
|
|
$1,347,050
|
$1,400,949
|
$173
|
$196
|
$220
|
$243
|
$267
|
$290
|
$314
|
$337
|
$361
|
$384
|
|
$1,400,950
|
$1,454,849
|
$149
|
$173
|
$196
|
$220
|
$243
|
$267
|
$290
|
$314
|
$337
|
$361
|
|
$1,454,850
|
$1,508,699
|
$126
|
$149
|
$173
|
$196
|
$220
|
$243
|
$267
|
$290
|
$314
|
$337
|
|
$1,508,700
|
$1,562,549
|
$120
|
$126
|
$149
|
$173
|
$196
|
$220
|
$243
|
$267
|
$290
|
$314
|
|
$1,562,550
|
$1,616,449
|
$92
|
$120
|
$126
|
$149
|
$173
|
$196
|
$220
|
$243
|
$267
|
$290
|
|
$1,616,450
|
$1,670,399
|
$74
|
$92
|
$120
|
$126
|
$149
|
$173
|
$196
|
$220
|
$243
|
$267
|
|
$1,670,400
|
$1,724,299
|
$42
|
$74
|
$92
|
$120
|
$126
|
$149
|
$173
|
$196
|
$220
|
$243
|
|
$1,724,300
|
$1,778,149
|
$14
|
$42
|
$74
|
$92
|
$120
|
$126
|
$149
|
$173
|
$196
|
$220
|
|
$1,778,150
|
$1,832,049
|
|
$14
|
$42
|
$74
|
$92
|
$120
|
$126
|
$149
|
$173
|
$196
|
|
$1,832,050
|
$1,885,949
|
|
|
$14
|
$42
|
$74
|
$92
|
$120
|
$126
|
$149
|
$173
|
|
$1,885,950
|
$1,939,799
|
|
|
|
$14
|
$42
|
$74
|
$92
|
$120
|
$126
|
$149
|
|
$1,939,800
|
$1,993,699
|
|
|
|
|
$14
|
$42
|
$74
|
$92
|
$120
|
$126
|
|
$1,993,700
|
$2,047,599
|
|
|
|
|
|
$14
|
$42
|
$74
|
$92
|
$120
|
|
$2,047,600
|
$2,101,499
|
|
|
|
|
|
|
$14
|
$42
|
$74
|
$92
|
|
$2,101,500
|
$2,155,349
|
|
|
|
|
|
|
|
$14
|
$42
|
$74
|
|
$2,155,350
|
$2,209,299
|
|
|
|
|
|
|
|
|
$14
|
$42
|
|
$2,209,300
|
$2,263,265
|
|
|
|
|
|
|
|
|
|
$14
|
|
Form 8850
(Rev. March 2016)
Department of the Treasury
Internal Revenue Service
|
Pre-Screening Notice and Certification Request for
the Work Opportunity Credit
Information about Form 8850 and its separate instructions is at www.irs.gov/form8850.
|
OMB No. 1545-1500
|
| Signature—All Applicants Must Sign |
| Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete. |
| For Privacy Act and Paperwork Reduction Act Notice, see page 2. |
Cat. No. 22851L |
Form 8850 (Rev. 3-2016) |
 |
New York Youth Jobs Program
Harriman State Office Campus
Building 12, Room 412
Albany, NY 12240 |
New York Youth Jobs Program: 2019 Youth Certification
|
|
Use this form to apply for 2019 youth certification in the New York Youth Jobs Program.
The applicant (you), must complete all items: one through eighteen, except item 11. Item 11 is optional.
- If you are 16 or 17 years old your parent or guardian must sign and submit the application for you.
- If you have little or no access to a computer, mail the completed and signed application to the address above or fax it to (518) 485-1359. We do not accept applications submitted for you by a business or tax consultant.
- If you have questions or need help, please call (877) 226-5724 or email info@youthworks.ny.gov.
|
New York Youth Jobs Program: 2019 Youth Certification Qualifications:
|
|
To participate in the New York Youth Jobs Program:
- You must be 16 to 24 years old, and
- You must live in one of the target areas of New York State listed in item nine on page one, and
- You must be unemployed, and
- At least one of the following statements must apply to you:
- I am over 18 years of age and do not have a high school diploma or a General Educational Development (GED) or High School Equivalency (HSE) diploma.
- I am a member of a family that is receiving:
- Assistance from Temporary Assistance for Needy Families (TANF).
- Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps).
- Social Security Income (SSI) benefits.
- I am receiving a free or reduced-cost school lunch.
- I was referred to this program by a rehabilitation agency approved by the state, or an employment network under the Ticket to Work Program.
- I have served time in jail or prison or I am on probation or parole.
- I am pregnant or a parent.
- I am homeless.
- I am currently or was in foster care or the custody of the Office of Children and Family Services.
- I am a veteran.
- I am the daughter or son of a parent who is currently in jail or prison, or was in jail or prison within the past two years.
- I am the daughter or son of a parent who is collecting unemployment insurance.
- I live in public housing or receive housing assistance such as a Section 8 voucher.
- I have another risk factor not identified above
|
18. Agreement:
- I swear that I currently meet the qualifications listed above in the New York Youth Jobs Program: 2019 Youth Certification Qualifications section.
- I understand that I must provide private, personal information on this application to qualify for the program.
- I understand that I do not need to explain why I qualify to anyone I ask for a job, or who gives me a job, or anyone who I work with.
- I agree to allow the New York State Department of Taxation and Finance to share my wage record with the New York State Department of Labor.
- I believe the information submitted in this application is true, correct and complete.
- I understand that the New York State Department of Labor will make sure the information submitted in this application is true and may ask me for more information or details.
- I am aware that there are consequences for filing false documents or other information with the government.
I agree to the statements above.
|
|