I certify that the information on this form is correct and that, for the year 2009, I expect

Employee’s signature

Date

to qualify for exemption from withholding of New York State income tax under

section 671(a)(3) of the Tax Law. I will notify my employer within 10 days of any change

requiring revocation of the exemption from withholding as explained in the instructions.

Employer name and address

(Employer: complete this section only if you must

Employer identification number

send a copy to the NYS Tax Department; see instructions)

Employee

Who qualifes —

You may claim exemption from withholding if: (1) you are

under age 18, over age 65, or a full-time student under age 25,

and

(2) you

had no New York income tax liability for 2008,

and

(3) expect none for the

year 2009. (For this purpose, you have a tax liability if your return shows tax

before the allowance of any credit for income tax withheld.)

If you meet these conditions, file this certificate, Form IT-2104-E, with your

employer. Otherwise, your employer must withhold New York State income tax

(and New York City and Yonkers personal income tax, if applicable) from your

wages. Do not send this certificate to the Tax Department.

Generally, as a resident, you are required to file a New York State income

tax return if you are required to file a federal income tax return, or if your

federal adjusted gross income plus your New York additions is more than

$4,000, regardless of your filing status. However, if you are single and can

be claimed as a dependent on another person’s federal return, you must

file a New York State return if your federal adjusted gross income plus your

New York additions is more than $3,000.

If you are a nonresident and have income from New York sources, you

must file a New York return if the sum of your federal adjusted gross income

and New York additions to income is more than your New York standard

deduction.

A penalty of $500 may be imposed for furnishing false information that

decreases your withholding amount.

When to claim exemption from withholding —

File this certificate

with your employer if you meet all the conditions listed above.

You must

fle a new certifcate each year if you wish to continue to claim the

exemption.

Liability for estimated tax —

If, as a result of this exemption certificate,

your employer does not withhold income tax from your wages and you later

fail to qualify for exemption from tax, you may be required to pay estimated

tax and be subject to penalty if it is not paid. For further information, see

Form IT-2105,

Estimated Income Tax Payment Voucher for Individuals.

Multiple employers —

If you have more than one employer, you may

claim exemption from withholding with each employer as long as your total

expected income will not cause you to incur a New York income tax liability

for the year 2009 and you had no liability for 2008.

Revocation by employee —

You must revoke this exemption certificate

(1) within 10 days from the day you expect to incur a New York income

tax liability for the year 2009, or (2) on or before December 1, 2009, if you

expect to incur a tax liability for 2010.

If you are required to revoke this certificate, if you no longer meet the age

requirements for claiming exemption, or if you want income tax withheld

from your pay (because, for example, you expect your income to exceed

$3,000), you

must

file Form IT-2104,

Employee’s Withholding Allowance

Certifcate,

with your employer. Follow the instructions on Form IT-2104 to

determine the correct number of allowances to claim for withholding tax

purposes.

Filing status —

Mark an

X

in one box on Form IT-2104-E that shows your

present filing status for federal purposes.

Need help? —

If you need help completing this form, call toll free

1 800 225-5829 (for employees) or 1 877 698-2910 (for employers). From

areas outside the U.S. and outside Canada, call (518) 485-6800.

Employer

Keep this certificate with your records. If an employee who claims exemption

from withholding on Form IT-2104-E usually earns more than $200 per

week, you

must

send a copy of that employee’s Form IT-2104-E to:

NYS Tax

Department, Income Tax Audit Administrator, Withholding Certifcate

Coordinator, W A Harriman Campus, Albany NY 12227.

The Tax Department will not accept this form if it is incomplete. We will

review these certificates and notify you of any adjustments that must be

made.

Due dates for sending certificates received from employees who claim

exemption and earn more than $200 per week are:

Quarter

Due date

Quarter

Due date

January – March

April 30

July – September

October 31

April – June

July 31

October – December

January 31

Revocation by employer —

You must revoke this exemption within 10

days if, on any day during the calendar year, the date of birth stated on the

certificate filed by the employee indicates the employee no longer meets

the age requirements for exemption. The revocation must be in the form of a

written notice to the employee.

New hires —

If you are submitting a copy of this form because you are

choosing to use this form to comply with New York State’s New Hire

Reporting Program, mark an

X

in the box and mail a copy of the completed

form, within 20 days of hiring, to:

NYS TAX DEPARTMENT, NEW HIRE NOTIFICATION

PO BOX 15119, ALBANY NY 12212-5119

To report newly-hired employees online go to

www.nynewhire.com

.

Privacy notifcation —

The Commissioner of Taxation and Finance may collect and

maintain personal information pursuant to the New York State Tax Law, including but

not limited to, sections 5-a, 171, 171-a, 287, 308, 429, 475, 505, 697, 1096, 1142, and

1415 of that Law; and may require disclosure of social security numbers pursuant to

42 USC 405(c)(2)(C)(i).

This information will be used to determine and administer tax liabilities and, when

authorized by law, for certain tax offset and exchange of tax information programs as

well as for any other lawful purpose.

Information concerning quarterly wages paid to employees is provided to certain

state agencies for purposes of fraud prevention, support enforcement, evaluation of

the effectiveness of certain employment and training programs and other purposes

authorized by law.

Failure to provide the required information may subject you to civil or criminal penalties,

or both, under the Tax Law.

This information is maintained by the Director of Records Management and Data

Entry, NYS Tax Department, W A Harriman Campus, Albany NY 12227; telephone

1 800 225-5829. From areas outside the United States and outside Canada, call

(518) 485-6800.

Cut here and give the above certificate to your employer

Instructions

First name and middle initial

Last name

Social security number

Mailing address

(number and street or rural route)

Apartment number

Date of birth

(mm-dd-yyyy)

City, village, or post office

State

ZIP code

Are you a full-time student?

Yes

No

Print or type

New York State Department of Taxation and Finance

Certifcate of Exemption from Withholding

New York State • New York City • Yonkers

This certifcate will expire on April 30, 2010.

Mark an

X

if a newly

hired employee

Filing status: Mark an

X

in only one box

A

Single

B

Married

C

Qualifying widow(er)

with dependent child, or

head of household with

qualifying person

To claim exemption from withholding for New York State personal income tax (and New York City and Yonkers personal income tax, if applicable), you must

meet

all

of the following conditions:

• you must be under age 18, or over age 65, or a full‑time student under age 25;

and

• you did

not

have a New York income tax liability for 2008;

and

• you do

not

expect to have a New York income tax liability for 2009.

If you

do not meet all

of the above conditions,

stop;

you cannot claim exemption from withholding.