State Withholding Certificate (NJ-W4 / PA / IT-2104 / CT-W4)

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State income-tax withholding elections for New Jersey (NJ-W4), Pennsylvania (Residency Certification REV-419 / local EIT), New York (IT-2104), and Connecticut (CT-W4).

BTL-PBL-05.012

Form

Vol 05 — Human Resources & Talent

Employee

Full name *

SSN *

Home address & ZIP *

State of residence *— NJ · PA · NY · CT · Other.

State where work is primarily performed *

New Jersey — Form NJ-W4 (only if NJ resident or NJ work)

NJ filing status (Line 2)— A Single · B Married/CU joint · C Married/CU separate · D Head of Household · E Qualifying widow(er).

Number of allowances (Line 3)

Wage chart letter (A/B/C/D/E) if two-earner household (Line 4)

Additional NJ withholding per pay (Line 5)

Exempt claim (Line 6) — I incurred no NJ tax liability last year & expect none this year

Yes / N/A

Pennsylvania — Residency Certification / REV-419

PA resident? Complete Residency Certification form (PSD code)— PA has flat 3.07% state tax; local EIT withheld at higher of work-location or resident PSD rate.

Municipality of residence & PSD code

REV-419 non-withholding — reciprocal state (IN/MD/NJ/OH/VA/WV) or exemption

New York — Form IT-2104

NY filing status— Single or Head of Household · Married.

Total NY State allowances (Line 1)

Total NYC allowances (Line 2, if NYC resident)

Yonkers allowances (Line 3, if Yonkers resident)

Additional NY State withholding per pay (Line 4)

Additional NYC withholding (Line 5)

Additional Yonkers withholding (Line 6)

IT-2104-E exemption claim (met last year & expect to this year)

Yes / N/A

Connecticut — Form CT-W4

CT withholding code (A/B/C/D/E/F)— A Single · B Head of Household · C MFJ both spouses working · D MFJ one spouse working · E MFS · F Qualifying widow(er).

Additional CT withholding per pay (Line 2)

Reduced withholding amount (Line 3)

Employee Signature

Under penalties of perjury, I declare the information is true and correct. *

Yes / N/A

Employee signature *

Date *

Prepared by

Name · Title · Date

Reviewed by

Name · Title · Date

Approved by

Owner · Katheryn L. Wilkins · Date

Controlled document — BTL-PBL-05.012. Complete all required fields (marked *). Retain per Volume 15 retention schedule.