Form W-4S Request for Federal Income Tax OMB No.

1545-0717

Withholding From Sick Pay

Department of the Treasury
Internal Revenue Service © Give this form to the third-party payer of your sick pay.
1999
Type or print your full 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 income tax withholding from my sick pay payments. I want the following amount to be withheld from each
payment. (See worksheet below.) $

Employee’s signature © ©
Date

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

Worksheet (Keep for your records. Do not send to the Internal Revenue Service.)
1 Enter amount of adjusted gross income you expect in 1999 1

2 If you plan to itemize deductions on Schedule A (Form 1040), enter the estimated total of your deductions.
For 1999, you may have to reduce your itemized deductions if your income is over $126,600 ($63,300 if
married filing separately). Get Pub. 919, Is My Withholding Correct for 1999?, for details. Call 1-800-829-3676
to order this and any other IRS publication or form you may need. If you do not plan to itemize deductions,
enter the standard deduction (see the instructions on page 2 for the standard deduction amount, including
additional amounts for age and blindness) 2
3 Subtract line 2 from line 1 3

4 Exemptions. Multiply $2,750 by the number of personal exemptions. For 1999, the value of your personal
exemption(s) is reduced if your income is over $126,600 if single, $189,950 if married filing jointly or qualifying
widow(er), $94,975 if married filing separately, or $158,300 if head of household. Get Pub. 919 for details 4
5 Subtract line 4 from line 3 5
6 Tax. Figure your tax on line 5 by using the 1999 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 1998 Form 1040, 1040A, or 1040EZ instructions 6
7 Credits (the child tax and higher education credits, credit for child and dependent care expenses, etc.) 7
8 Subtract line 7 from line 6 8
9 Estimated income tax withheld and to be withheld from other sources (including amounts withheld due to
a prior Form W-4S) during 1999 or paid with Form 1040-ES 9
10 Subtract line 9 from line 8 10
11 Enter the number of sick pay payments you expect to receive this year to which this Form W-4S will apply 11
12 Divide line 10 by line 11. Round to the nearest dollar. This is the amount that should be withheld from each
sick pay payment. Be sure it meets the requirements for the amount that should be withheld, as explained
under Amount to be withheld below. If it does, enter this amount on Form W-4S above 12

General Instructions 1. Must be in whole dollars (for example, $35, not $34.50).
Purpose of form. Give this form to the third-party payer of your sick 2. Must be at least $20 a week.
pay, such as an insurance company, if you want Federal income tax 3. Must not reduce the net amount of each sick pay payment you
withheld from the payments. You are not required to have Federal receive to less than $10.
income tax withheld from sick pay paid by a third party. However, if 4. For payments larger or smaller than a regular full payment of
you choose to request such withholding, Internal Revenue Code sick pay, the amount withheld will be in the same proportion as your
sections 3402(o) and 6109 and their regulations require you to regular withholding from sick pay. For example, if your regular full
provide the information requested on this form. You do not have to payment of $100 a week normally has $25 (25%) withheld, then $20
use this form if your employer makes the payments because (25%) will be withheld from a partial payment of $80.
employers are already required to withhold income tax from sick pay. Caution: You may be subject to a penalty if your tax payments
Note: If you receive sick pay under a collective bargaining during the year are not at least 90% of the actual tax shown on your
agreement, see your union representative or employer. tax return. For more information, see Pub. 505, Tax Withholding and
Definition. Sick pay is a payment you receive: Estimated Tax. You may pay tax during the year through withholding
or estimated tax payments or both. To avoid a penalty, make sure
1. Under a plan your employer takes part in and you have enough tax withheld or file Form 1040-ES, Estimated Tax
2. In place of wages for any period when you are temporarily for Individuals. You may estimate your income tax liability by using
absent from work because of sickness or injury. the worksheet above.
Amount to be withheld. Enter on this form the amount you want Sign this form. Form W-4S is not valid unless you sign it.
withheld from each payment. The amount you enter: (Continued on back.)

For Paperwork Reduction Act Notice, see page 2. Cat. No. 10226E Form W-4S (1999)
Form W-4S (1999) Page 2
Statement of income tax withheld. After the end of the year, you Single $4,300*
will receive a Form W-2 reporting the taxable sick pay paid and Married filing separately $3,600*
income tax withheld during the year. These amounts are reported to *If you are age 65 or over or blind, add to this amount the additional
the Internal Revenue Service. amount that applies to you as shown in the next paragraph. If you
Changing your withholding. Form W-4S remains in effect until you can be claimed as a dependent on another person’s return, see
change or revoke it. You may do this by giving a new Form W-4S or Limited standard deduction for dependents below.
a written notice to the payer of your sick pay. To revoke your Additional amount for the elderly or blind. An additional standard
previous Form W-4S, write “Revoked” in the money amount box on deduction of $850 is allowed for a married individual (filing jointly or
Form W-4S, and give it to the payer. separately) or qualifying widow(er) who is 65 or older or blind, $1,700
if 65 or older and blind. If both spouses are 65 or older, an
Worksheet additional $1,700 is allowed on a joint return ($1,700 on a separate
You may use the worksheet on page 1 to estimate the amount of return if you can claim an exemption for your spouse). If both
income tax you want withheld from each sick pay payment. Use spouses are 65 or older and blind, an additional $3,400 is allowed
your tax return for last year and the worksheet as a basis for on a joint return ($3,400 on a separate return if you can claim an
estimating your tax, tax credits, and withholding for this year. exemption for your spouse). An additional standard deduction of
You may not want to use Form W-4S if you already have your $1,050 is allowed for an unmarried individual (single or head of
total tax covered by estimated tax payments or other withholding. household) who is 65 or older or blind, $2,100 if 65 or older and
blind.
If you expect to file a joint return, be sure to include the income,
deductions, credits, and payments of both yourself and your spouse Limited standard deduction for dependents. If you can be claimed
in figuring the amount you want withheld. as a dependent on another person’s return, your standard deduction
is the greater of (a) $700 or (b) your earned income plus $250 (up to
Caution: If any of the amounts on the worksheet change after you the regular standard deduction for your filing status). If you are age
give Form W-4S to the payer, you may use a new Form W-4S to 65 or over or blind, see Pub. 505 for additional amounts you may
request a change in the amount withheld. claim.
Certain individuals not eligible for standard deduction. For the
Specific Instructions following individuals, the standard deduction is zero:
Worksheet on Page 1 1. A married individual filing a separate return if either spouse
itemizes deductions.
Line 2—Deductions 2. A nonresident alien individual.
Itemized deductions. You may have to reduce your itemized 3. An individual filing a return for a period of less than 12 months
deductions if your income is over $126,600 ($63,300 if married filing because of a change in his or her annual accounting period.
separately). Get Pub. 919 for details. Line 6—Tax. Use the appropriate Tax Rate Schedule below to figure
Standard deduction, individuals (other than the elderly or blind). your tax.
For 1999, the amounts are: Line 7—Credits. Include on this line any tax credits you are entitled
Standard to claim, such as the child tax and higher education credits, credit
Filing Status Deduction for child and dependent care expenses, earned income credit, or
credit for the elderly or the disabled.
Married filing jointly or qualifying widow(er) $7,200*
Line 9. Enter the income tax you expect will be withheld this year on
Head of household $6,350* income other than sick pay and any payments you made using Form
1040-ES. Include income tax withheld from wages and pensions.

1999 Tax Rate Schedules

Single—Schedule X Head of household—Schedule Z
If line 5 is: The tax is: of the If line 5 is: The tax is: of the
But not amount But not amount
Over— over— over— Over— over— over—

$0 $25,750 15% $0 $0 $34,550 15% $0

25,750 62,450 $3,862.50 + 28% 25,750 34,550 89,150 $5,182.50 + 28% 34,550
62,450 130,250 14,138.50 + 31% 62,450 89,150 144,400 20,470.50 + 31% 89,150
130,250 283,150 35,156.50 + 36% 130,250 144,400 283,150 37,598.00 + 36% 144,400
283,150 90,200.50 + 39.6% 283,150 283,150 87,548.00 + 39.6% 283,150
Married filing jointly or Qualifying widow(er)—Schedule Y-1 Married filing separately—Schedule Y-2
If line 5 is: The tax is: of the If line 5 is: The tax is: of the
But not amount But not amount
Over— over— over— Over— over— over—

$0 $43,050 15% $0 $0 $21,525 15% $0

43,050 104,050 $6,457.50 + 28% 43,050 21,525 52,025 $3,228.75 + 28% 21,525
104,050 158,550 23,537.50 + 31% 104,050 52,025 79,275 11,768.75 + 31% 52,025
158,550 283,150 40,432.50 + 36% 158,550 79,275 141,575 20,216.25 + 36% 79,275
283,150 85,288.50 + 39.6% 283,150 141,575 42,644.25 + 39.6% 141,575
Paperwork Reduction Act Notice. We ask for the information on The time needed to complete this form will vary depending on
this form to carry out the Internal Revenue laws of the United States. individual circumstances. The estimated average time is:
You are not required to provide the information requested on a Recordkeeping 40 min.; Learning about the law or the form 7
form that is subject to the Paperwork Reduction Act unless the form min.; Preparing the form 37 min.
displays a valid OMB control number. Books or records relating to a If you have comments concerning the accuracy of these time
form or its instructions must be retained as long as their contents estimates or suggestions for making this form simpler, we would be
may become material in the administration of any Internal Revenue happy to hear from you. You can write to the Tax Forms Committee,
law. Generally, tax returns and return information are confidential, as Western Area Distribution Center, Rancho Cordova, CA 95743-0001.
required by Code section 6103. DO NOT send the tax form to this address. Instead, give it to your
payer.