Minnesota W-4MN

Minnesota Employee Withholding Allowance/Exemption Certificate — filled onto the official form.

Form W-4MN — Minnesota Withholding Allowance/Exemption Certificate. Complete Section 1 (allowances) or Section 2 (exemption), not both. Entries are placed onto the official Minnesota Revenue form and archived with your signature.

Employee Information

First name and initial

Last name

Social Security number

Permanent address

City

State

ZIP code

Marital status:

Single; or married but legally separated; or spouse is a nonresident alien Married Married, but withhold at higher Single rate

Section 1 — Determining Minnesota Allowances

A — Yourself (enter 1 or 0)

B — Your spouse (1 or 0)

C — Spouse works / second job (1 or 0)

D — Dependents you will claim

E — Head of household (1 or 0)

F — Total allowances (add A–E)

1 — Minnesota allowances (from F)

2 — Additional MN withholding per pay period ($)

Section 2 — Exemption From Minnesota Withholding (only if it applies)

Box A — Exempt from federal AND Minnesota withholding Box B — Exempt from Minnesota only Box C — Military spouse (MSRRA) Box D — American Indian on reservation Box E — MN National Guard / active duty Box F — Military pension/retirement pay

State of domicile (Box C only)

Reservation name (Box D only)

Sign Here

I certify all information is correct. I understand there is a $500 penalty for filing a false Form W-4MN.

Daytime phone

Employee signature

Employer Section (completed by Bella Mente)

Employer name

FEIN

Minnesota Tax ID

Employer address

City

State

ZIP