Request for Federal Income Tax OMB No. 1545-0717

Form W-4S Withholding From Sick Pay

Department of the Treasury

Internal Revenue Service

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 

Worksheet (Keep for your records. Do not send to the Internal Revenue Service.)

1 Enter amount of adjusted gross income you expect in 2003 1

If you plan to itemize deductions on Schedule A (Form 1040), enter the estimated total of your deductions.

For 2003, you may have to reduce your itemized deductions if your income is over $139,500

($69,750 if married filing separately). See Pub. 919, How Do I Adjust My Tax Withholding? for details. Call

1-800-829-3676 or visit the IRS Web Site at www.irs.gov to order forms and publications. 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

2

3 Subtract line 2 from line 1 3

Exemptions. Multiply $3,050 by the number of personal exemptions. For 2003, your personal exemption(s)

amount is reduced if your income is over $139,500 if single, $209,250 if married filing jointly or qualifying

widow(er), $104,625 if married filing separately, or $174,400 if head of household. See Pub. 919 for details.

4

4

5 Subtract line 4 from line 3 5

Tax. Figure your tax on line 5 by using the 2003 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 2002 Form 1040, 1040A, or 1040EZ instructions

6

6

7 Credits (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 2003 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

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

12

2. In place of wages for any period when you are temporarily

absent from work because of sickness or injury.

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 are not 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. Do not use this form

if your employer (or its agent) makes the payments because

employers are already required to withhold 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 you receive:

1. Under a plan your employer takes part in and

(continued on back)

Form W-4S (2003)

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

For Paperwork Reduction Act Notice, see page 2. Cat. No. 10226E

 Give this form to the third-party payer of your sick pay.

● Must not reduce the net amount of each sick pay payment 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.

Amount to be withheld. Enter on this form the amount you want

withheld from each payment. The amount you enter:

● Must be in whole dollars (for example, $35, not $34.50).

● Must be at least $20 a week.

Caution: Generally, you may be subject to a penalty if your tax

payments during the year are not at least 90% of the tax shown on

your tax return. For exceptions and more 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 you have enough tax withheld or file Form

1040-ES, Estimated Tax for Individuals. You may estimate your

income tax liability by using the worksheet above.

General Instructions

2003
Form W-4S (2003) Page 2

Itemized deductions. You may have to reduce your itemized

deductions if your income is over $139,500 ($69,750 if married filing

separately). See Pub. 919 for details.

Certain individuals not eligible for standard deduction. For the

following individuals, the standard deduction is zero:

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.

Standard deduction, individuals (other than the elderly or blind).

For 2003, the amounts are:

● A nonresident alien individual.

● An individual filing a return for a period of less than 12 months

because of a change in his or her annual accounting period.

You may use the worksheet on page 1 to estimate the amount of

income tax 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.

Filing Status

Married filing jointly or qualifying widow(er) $7,950*

Head of household $7,000*

Include on this line any tax credits you are entitled to claim, such as

the child tax and higher education credits, credit for child and

dependent care expenses, earned income credit, or credit for the

elderly or the disabled.

Single $4,750*

Married filing separately $3,975*

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 are age 65 or older or blind, add to this 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 below.

Enter the income tax you expect will be withheld this year on income

other than sick pay and any payments you made using Form

1040-ES. Include income tax withheld from wages and pensions.

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.

2003 Tax Rate Schedules

Schedule X—Single Schedule Z—Head of household

If line 5 is: The tax is: If line 5 is: The tax is: of the

amount

over—

of the

amount

over— But not

over—

But not

Over— over— Over—

$0

6,000

28,400

68,800

143,500

311,950

$6,000

28,400

68,800

143,500

311,950

$0

6,000

28,400

68,800

143,500

311,950

Schedule Y-1—Married filing jointly or Qualifying widow(er) Schedule Y-2—Married filing separately

of the

amount

over—

of the

amount

over—

If line 5 is: The tax is: If line 5 is: The tax is:

But not

over—

But not

Over— over— Over—

● A married individual filing a separate return if either spouse

itemizes deductions.

10%

$600.00 + 15%

3,960.00 + 27%

14,868.00 + 30%

37,278.00 + 35%

96,235.50 + 38.6%

$0

12,000

47,450

114,650

174,700

311,950

$12,000

47,450

114,650

174,700

311,950

$0

12,000

47,450

114,650

174,700

311,950

10%

$1,200.00 + 15%

6,517.50 + 27%

24,661.50 + 30%

42,676.50 + 35%

90,714.00 + 38.6%

$0

10,000

38,050

98,250

159,100

311,950

$10,000

38,050

98,250

159,100

311,950

$0

10,000

38,050

98,250

159,100

311,950

10%

$1,000.00 + 15%

5,207.50 + 27%

21,461.50 + 30%

39,716.50 + 35%

93,214.00 + 38.6%

$0

6,000

23,725

57,325

87,350

155,975

$6,000

23,725

57,325

87,350

155,975

$0

6,000

23,725

57,325

87,350

155,975

10%

$600.00 + 15%

3,258.75 + 27%

12,330.75 + 30%

21,338.25 + 35%

45,357.00 + 38.6%

Caution: If any of the amounts on the worksheet change after you

give Form W-4S to the payer, you may use a new Form W-4S to

request a change in the amount withheld.

Standard

Deduction

Specific Instructions for Worksheet

Limited standard deduction for dependents. If you can be

claimed as a dependent on another person’s return, your standard

deduction is the greater of: (a) $750 or (b) your earned income plus

$250 (up to the regular standard deduction for your filing status). If

you are 65 or older or blind, see Pub. 505 for additional amounts

you may claim.

Line 2—Deductions

Additional amount for the elderly or blind. An additional

standard deduction of $950 is allowed for a married individual (filing

jointly or separately) or qualifying widow(er) who is 65 or older or

blind, $1,900 if 65 or older and blind. If both spouses are 65 or older

or blind, an additional $1,900 is allowed on a joint return ($1,900 on

a separate return if you can claim an exemption for your spouse). If

both spouses are 65 or older and blind, an additional $3,800 is

allowed on a joint return ($3,800 on a separate return if you can

claim an exemption for your spouse). An additional $1,150 is allowed

for an unmarried individual (single or head of household) who is 65

or older or blind, $2,300 if 65 or older and blind.

Paperwork Reduction Act Notice. We ask for the information on

this form to carry out the Internal Revenue laws of the United States.

The time needed to complete this form will vary depending on

individual circumstances. The estimated average time is:

Recordkeeping—39 min.; Learning about the law or the form—10

min.; Preparing and sending the form—41 min.

If you have comments concerning the accuracy of these time

estimates or suggestions for making this form simpler, we would be

happy to hear from you. You can write to the Tax Forms Committee,

Western Area Distribution Center, Rancho Cordova, CA 95743-0001.

Do not send the tax form to this address. Instead, give it to your

payer.

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.

Statement of income tax withheld. After the end of the year, you

will receive a Form W-2, Wage and Tax Statement, reporting the

taxable sick pay paid and income tax withheld during the year.

These amounts are reported to the Internal Revenue Service.

Line 7—Credits

Line 9—Tax Withholding and Estimated Tax

Sign this form. Form W-4S is not valid unless you sign it.