CT – Horizons Portal

If Not “Qualifying Widow(er) With Dependent Child” Leave blank and Continue to Next Page
Qualifying Widow(er) With Dependent Child
- Withholding Code E: My expected annual gross income is less than or equal to $24,000 or I am claiming exemption under the MSRRA* and no withholding is necessary.
- Withholding Code C: My expected annual gross income is greater than $24,000.
- Withholding Code D: I have significant nonwage income and wish to avoid having too little tax withheld.
- Withholding Code D: I am a nonresident of Connecticut with substantial other income.

If Not “Married Filing Separately” Leave blank and Continue to Next Page
Married Filing Separately
- Withholding Code E: My expected annual gross income is less than or equal to $12,000 or I am claiming exemption under the MSRRA* and no withholding is necessary.
- Withholding Code A: My expected annual gross income is greater than $12,000.
- Withholding Code D: I have significant nonwage income and wish to avoid having too little tax withheld.
- Withholding Code D: I am a nonresident of Connecticut with substantial other income.

If Not “Single” Leave blank and Continue to Next Page
Single
- Withholding Code E: My expected annual gross income is less than or equal to $15,000 and no withholding is necessary.
- Withholding Code F: My expected annual gross income is greater than $15,000.
- Withholding Code D: I have significant nonwage income and wish to avoid having too little tax withheld.
- Withholding Code D: I am a nonresident of Connecticut with substantial other income.

If Not “Head of Household” Leave blank and Continue to Next Page
Head of Household
- Withholding Code E: My expected annual gross income is less than or equal to $19,000 and no withholding is necessary.
- Withholding Code B: My expected annual gross income is greater than $19,000.
- Withholding Code D: I have significant nonwage income and wish to avoid having too little tax withheld.
- Withholding Code D: I am a nonresident of Connecticut with substantial other income.

Employees
MSRRA
- Check if you are claiming the MSRRA exemption and enter state of legal residence/domicile:
1. Withholding Code: Enter Withholding Code letter chosen from previous page
2. Additional withholding amount per pay period: If any
3. Reduced withholding amount per pay period: If any

Declaration: I declare under penalty of law that I have examined this certificate and, to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for reporting false information is a fine of not more than $5,000, imprisonment for not more than five years, or both.
Declaration*
- I certify the above statement
Social Security Number*
Employee Signature – Type Your Name*
Today's Date*
My IP Address is: 44.192.115.114
This form was submitted on: 09/21/2023

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