Access State Withholding Form in Brooklyn, NY | BSHHA Home Health Care & Staffing Agency

Before making any entries, see the Note below, and if applicable, complete the worksheet in the instructions

1. Total number of allowances you are claiming for New York State and Yonkers, if applicable (from line 19, if using worksheet)

2. Total number of allowances for New York City (from line 31, if using worksheet)

Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer

3. New York State amount

4. New York City amount .

I certify that I am entitled to the number of withholding allowances claimed on this certificate.
Penalty – A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld from your wages. You may also be subject to criminal penalties.

Employee’s signature (This form is not valid unless you sign it.)

Date

Name

This field is for validation purposes and should be left unchanged.

State Withholding Form

Employee’s Withholding Allowance Certificate

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