Form IT-2104:2013:Employee's Withholding Allowance Certificate: IT2104

Instructions

IT-2104

First name and middle initial

Last name

Your social security number

Permanent home address

(number and street or rural route)

Apartment number

City, village, or post office

State

ZIP code

Are you a resident of New York City? ...........

Yes

Are you a resident of Yonkers? .....................

Yes

Complete the worksheet on page 3 before making any entries.

Total number of allowancesYork you State areYonkers, claiming and if

(from

applicablefor

line

17)

New...........

Total number of allowances for New York City

(from line 28)

..................................................................................

Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.

NewY ork State........................................................................................................................................

amount

New York City amount ...........................................................................................................................................

Yonkers amount ....................................................................................................................................................

NewY ork State DepartmentTaxation and of Finance

Employee’s WithholdingAllowance Certifcate

NewY ork StateYork • New CityY onkers •

Single or Head of householdMarried

Married, but withhold at higher single rate

Note:

If married but legally separated,

the

Single or Head of household

box.

I certify that I am entitled to the number of withholding allowances claimed

Employee’signature s

Date

Employer’s name and address

(Employer: complete this section only if you are sending a copy of this form to the NYS Tax Department.)

Employer identification number

Penalty –

A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld

from your wages. You may also be subject to criminal penalties.

Employee: detach this page and give it to your employer; keep a copy for your records.

Changes effective for 2013

Form IT-2104 has been revisedThe for worksheet tax year on 2013.

page 3 used to compute your withholding allowances and the charts

beginning on page 4 used to enter an additional dollar amount of

withholding have been revised. If you previously filed a Form IT-2104

and used the worksheet or charts, you should complete a new 2013

Form IT-2104 and give it to your employer.

Who should fle this form

This certificate, Form IT-2104, is completed by an employee and given

to the employer to instruct Ytheork employer State (and how much New

NewY ork CityYonkers) and tax to withhold fromThe the employee’s pay.

more allowances claimed, the lower the amount of tax withheld.

If you do not file Form IT-2104, your employer may use the same number

of allowances you claimed-4. Due on tofederal differences Form W in

tax law, this may result in the wrongYork amount

of tax withheld for New

State,Y Nework CityYonkers., and Complete Form IT-2104 each year

and file it with your employer if the number of allowances you may claim

is different from federal Form W-4 or has changed.

completingForm a new IT-2104

each year include the

• You started a new job.

• You are no longer a dependent.

• Your individual circumstances may have changed

were married or have an additional child).

• You itemize your deductions on your personal

• You claim allowancesYork State for New credits.

• You owed tax or received a large refund when

income tax return for the past year.

• Your wages have increased and you expect

during the tax year.

• The total income of you and your spouse has

more for the tax year.

• You have significantly moresources or less orincome from

another job.

• You no longer qualify for exemption from

• You have been advised by the Internal Revenue

are entitled to fewer allowances than claimed on your original federal

Form W-4, and the disallowed allowances were

Form-2104. IT

Instructions

Employers only:

Mark an

in Abox and/or

box B to indicate why you are sendingYork State

(see

instr

copy

of this

A Employee claimed more than 14 exemption............

A allowances for NYS

B Employee is a new... hire B

or a rehire

First

ate employee

performed services for pay

(mm-dd-yyyy) (see instr.)

Are dependent health insurance benefits............. availableYes

for this employee?

, enter

the date the

(mm-dd-yyyy)

employee:

qualifies

IT-2104

Page 2

of 7

IT-2104

(2013)

Exemption from withholding

You cannot use Form IT-2104 to claim exemption from withholding.

To claim exemption from income

must

file tax withholding, you

Form IT-2104-E,

Certifcate of Exemption

, with your

from Withholding

employerYou must.

file a new certificate each year that you qualify for

exemption.This exemption from withholding is allowable only if you had

no NewYork

income tax liability in the prior year, you expect none in the

current year,

and

you are over 65 years of age, under 18, or a full-time

student underYou may 25. also

claim exemption from withholding if

you are a military spouse and meet the conditions set forth under the

ServicemembersAct Civil as amended Relief by the Military Spouses

ResidencyAct. Reliefyou If are a dependent who is under 18 or a

full-time student, you may owe tax if your income is more than $3,050.

Withholding allowances

You may

not

claim a withholding allowance for yourself or, if married,

your spouse. Claim the number of withholding allowances you compute

in Part 1 and Part 3 on page 3 of this form. If you want more tax

withheld, you may claim fewer allowances.

If you claim more than

14 allowances,

your employer

must send

a copy of your

Form IT-2104

to theY Nework StateTax Department.

You may then be asked to

verify your allowances. If you arrive at negative allowances (less than

zero) on lines 1 or 2 and your employer cannot accommodate negative

allowances,

enter

and see

Additional dollar amount(s)

below.

Income from sources other than wages –

If you have more than

$1,000 of income from sources other than wages (such as interest,

dividends, or alimony received), reduce the number of allowances

claimed on line(ifapplic 1 and lineable)the 2IT of-2104

certificate by one

for each $1,000 of nonwage income. If you arrive at negative allowances

(less than zero), see

Withholding

above. You may also

allowances

consider filing estimated tax, especially if you have significant amounts of

nonwage income. Estimated tax requires that payments be made by the

employee directlyTax Department to the

on a quarterly basis. For more

information, see the instructions-2105,

Estimated Income

for

Tax

Form IT

Payment Voucher for Individuals

, or see

Need help?

on page 6.

Other credits

(Worksheet

–

Ifline you 13)

will be eligible to claim

any credits other than the credits listed in the worksheet, such as an

investment tax credit, you may claim additional allowances.

Find your filing statusYork adjustedand your New gross

income (NYAGI)

in the chart belowthe, amountand divide of the

expected credit by the

number indicated. Enter the result (rounded to the nearest whole number)

on line 13.

Example:

You are married and expect your New York adjusted gross

income to be less than $308,750. In addition, you expect to receive a

flow-through of an investment tax credit from the S corporation of which

you are a shareholder. The investment tax credit will be $160. Divide

the expected credit by 66. 160/66 = 2.4242. The additional withholding

allowance(s) would

on line

be 13.2. Enter

Married couples with both spouses working

–

If you and your spouse

both work, you should each-2104 filecertificate a separate with IT your

respectiveY employers.our withholding

will better match your total tax if

the higher wage-earning spouse claims all of the couple’s allowances and

the lower wage-earning spouse

not

claimsclaim

zero allowances.

more total allowances than you are entitled to. If your combined wages

are:

• less than $102,900, you should

in theeach box mark

Married,

but withhold at higher

on the certificate

single rate

front, and divide the

total number of allowances that you compute on line 17 and line 28 (if

applicable) between you and your working spouse.

• $102,900 or more, use the chart(s) in Part 4 and enter the additional

withholding dollar amount on line 3.

Taxpayers with more than one job

–

If you have more than one

file a separate IT-2104 certificate with each

sure to claim only the total number of allowances that you are entitled

to.Your

withholding will better match your

your allowances at your higher-paying job

the lower-paying job. In addition, to make sure

tax withheld,single if you taxpayer are a

or head of household

two or more jobs, and your combined wages from all jobs are under

$102,900, reduce the number of allowances by seven

line 2 (if applicable) on the certificate you

job employer. If you arrive at negative allowances

Withholding

allowances

above.

If you are a single or a head of household taxpayer,

wages from all of your jobs are between $102,900

the chart(s) in Part 5 and enter the additional

from the chart on line 3.

If you are a married taxpayer, and your combined

yourjobs

are $102,900 or more, use the chart(s) in

additional withholding dollar amount from

the words

Higher-paying

for

Higher

job earner’s wages

within the chart).

Dependents –

If you are a dependent of another taxpayer

your income to exceed $3,050, you should reduce

allowances by one for each $1,000This of income will over

ensure that your employer withholds enough

Following the above instructions will help to ensure that you will not owe

additional tax when you file your return.

Heads of households with only one job

–

you will use the

head-of-household filing status on your state

the

Single or Head of household

box on the front of the certificate.

have only one job, you may also wish to claim two additional withholding

allowances on line 14.

Additional dollar amount(s)

You may ask your employer to withhold an additional dollar amount each

pay periodcompleting by

lines 3, -4,2104. and In 5 most on Form

instances, if you compute a negative number of allowances and your

employer cannot accommodate a negative number, for each negative

allowance claimed you should have an additional

week forYork New State

withholding on line 3, and

of tax withheld perYork week City for withholding New Yonkers on line

residents should use Y15%ork (.15) State of the amount New for

withholding for Yonkers on line 5.

Note:

If you are requesting your employer to

amount on lines 3, 4, or 5 of this allowance

dollar amount, as determined by these instructions or by using the

chart(s) in Part 4 or Parta weekly 5, is Therefore,accuratepayroll. for

if you are not paid on a weekly basis, you will need to adjust the dollar

amount(s) that you compute. For example, if

must double the dollar amount(s) computed.

Avoid underwithholding

Form-2104, IT together with your employer’s withholding

designedtoensure thatthecorrect

amountof tax iswithheld

fromyour pay .

Ifyou fail tohave enough

taxwithheld

duringthe entire yearyou ,may owe

a large tax liability whenTheTax you Department file your return.must

assess interest and may impose penalties in certain situations in addition

to the tax liability. Even if you do not file

that you owe personal income tax, and we may

penalties on the amount of tax that you should have

Single and

NYAGI is:

Head of household

and NYAGI is:

Married

and NYAGI is:

Divide amount of

expected credit by:

Less than

$205,850

$257,300

$308,750

Between

Between Between

$205,850 and $257,300 and

$308,750 and

$1,029,250

$1,543,900

$2,058,550

Over

$1,029,250

$1,543,900

$2,058,550

(continued)

IT-2104

(2013)

Page 3

of 7

Worksheet

See the instructions before completing this worksheet.

Part 1 – Complete this part to compute your withholding allowances for New York State and Yonkers

(line

. 1)

Part 3 – Complete this part to compute your withholding allowances for New York City

(line

. 2)

Part 2 – Complete this part only if you expect to itemize deductions on your state return.

Enter your estimated federal itemized...........................................................................................

deductions for the tax

year

Enter your estimated state, local, and foreign income taxes........

state and local

Subtract line 19....................................................................................................................................................

from line 18

Enter your estimated college..........................................................................................................

tuition itemized deduction

Add lines 20.................................................................................................................................................................

and 21

Based on your federal filing status, enter the...........................................................

applicable amount

from the table

Single (cannot be claimed.... $ 7,700 as a dependent)

Qualifying........................................ widow(er) $15,400

Single (can be claimed....... as $ 3,050 a dependent)

Married filing.......................................... jointly $15,400

Head of household.........................................

$10,800

Married filing separate.........................

$ returns7,700

Subtract line

(if

line

from

23 is larger

line

than line

22, enter

here and on line

.......................................................

16 above)

Divide line 24 by $1,000. Drop any fraction and enter...................................................

the result here

and on line 16

Enter the amount from line 6 above .........................................................................................................................................

Add lines 14 through 16 above................................................................................................................

and enter total here

Add lines 26 and 27. Enter the.........................................................................................................

result here and on line 2

Enter the number of dependents that you will claim on your state return

(do not include yourself or, if married, your spouse)

.....

For lines 7, 8, and 9, enter

for each credit you expect to claim on your state return.

College tuition credit ..................................................................................................................................................................

NewY ork State household...............................................................................................................................................

credit

Real propertytax credit..............................................................................................................................................................

For lines 10, 11, and 12, enter

for each credit you expect to claim on your state return.

Child and dependent care credit ................................................................................................................................................

Earned

income

credit

.................................................................................................................................................................

Empire State............................................................................................................................................................

child credit

Other credits

(see instructions)

......................................................................................................................................................

Head of household

and

only one

statusjob

(enter

if the situation applies)

...................................................................................

Enter an estimate of your federal adjustments to income, such as alimony you

and deductible contributions IRA

you willTotal make estimate for the tax $ year . .

Divide this estimate by $1,000. Drop any..............................................................................

fraction and enter the number

If you expect to itemize deductions on your statethe numbertax return, from completeline 25. Part 2

All others enter

...................................................................................................................................................................

Add lines 6 through 16. Enter the result here and on line 1. If you have more than

work, see instructions for

Taxpayers with more

and

Married

than one

couples

job

with

both

..................

spouses

working

Standard deduction table

Employers

Box A –

If you are required to submit a copy of an employee’s

Form IT-2104T axto Departmentthe

because the employee claimed

more than 14 allowances,

in boxA and mark send an a copy

of Form IT-2104 to:

NYS Tax Department, Income Tax Audit

Administrator, Withholding CertifcateA Harriman Coordinator, W

Campus, Albany NY 12227.

Due dates for sending certificates received from employees claiming

more than 14 allowances are:

Quarter

Due date

Quarter

Due date

January – March

April 30

July – September

October 31

April – June

July 31

October – December

January 31

Box B –

If you are submitting a copy of this form

York State’s New Hire Reporting Program, mark

firstday any services are performed for which

wages, commissions, tips and any other type of compensation. For

services based solely on commissions, this

working for commissions is eligible to earn commissions. Also, mark an

in the

Yes

box indicating if dependent health

available to this, enter employee. the date If

the

employee

for coverage. Mail the completed form, within

Tax Department, New Hire Notifcation,Albany NY PO Box

12212-5119.

To report newly-hired or rehired employees

submitting this form, go to

www.nynewhire.com.

Page 4

of 7

IT-2104

(2013)

Part 4 –

These charts are only for married couples with both spouses working or married couples with one spouse working more than

one job, and whose combined wages are between $102,900 and $2,161,527.

Enter the additional withholding dollar amount on line 3.

The additional dollar amount, as shown below, is accurate for a weekly payroll.

adjust these dollar amount(s). For example, if you are paid biweekly, you must

$102,900

$123,500

$144,100

$164,650

$185,250

$226,400

$267,600

$308,750

$360,250

$411,700

$463,150

$123,499 $144,099

$164,649

$185,249

$226,399

$267,599

$308,749

$360,249

$411,699

$463,149

$514,599

$51,450

$72,049

$11

$15

$72,050

$92,599

$11

$16

$21

$26

$92,600

$113,199

$14

$19

$26

$33

$113,200

$123,499

$10

$15

$22

$31

$30

$123,500

$133,799

$13

$19

$29

$28

$133,800

$144,099

$10

$17

$26

$28

$25

$144,100

$154,349

$14

$24

$28

$23

$154,350

$164,649

$11

$21

$26

$23

$21

$164,650

$185,249

$16

$21

$22

$21

$18

$185,250

$226,399

$12

$17

$20

$18

$226,400

$267,599

$12

$23

$24

$18

$17

$267,600

$308,749

$17

$29

$25

$18

$308,750

$360,249

$10

$19

$26

$22

$360,250

$411,699

$15

$22

$411,700

$463,149

$15

$463,150

$514,599

Combined wages between $102,900 and $514,599

Higher earner’s wages

$514,600

$566,100

$617,550

$669,000

$720,500

$771,950

$823,400

$874,900

$926,350

$977,800 $1,029,250 $1,080,750

$566,099 $617,549

$668,999 $720,499 $771,949

$823,399

$874,899 $926,349 $977,799 $1,029,249 $1,080,749 $1,132,199

$267,600

$308,749

$19

$16

$308,750

$360,249

$14

$16

$18

$14

$360,250

$411,699

$18

$10

$12

$14

$411,700

$463,149

$22

$18

$10

$12

$14

$463,150

$514,599

$15

$22

$18

$10

$12

$14

$514,600

$566,099

$15

$22

$18

$10

$12

$14

$11

$566,100

$617,549

$15

$22

$18

$10

$12

$14

$11

$617,550

$668,999

$15

$22

$18

$10

$12

$14

$11

$669,000

$720,499

$15

$22

$18

$10

$12

$14

$11

$720,500

$771,949

$15

$22

$18

$10

$12

$16

$11

$771,950

$823,399

$15

$22

$18

$10

$14

$19

$823,400

$874,899

$15

$22

$18

$12

$17

$874,900

$926,349

$15

$22

$19

$15

$926,350

$977,799

$15

$23

$22

$977,800

$1,029,249

$17

$26

$1,029,250

$1,080,749

$18

$1,080,750

$1,132,199

Combined wages between $514,600 and $1,132,199

Higher earner’s wages

IT-2104

(2013)

Page 5

of 7

$1,132,200 $1,183,650 $1,235,150 $1,286,600 $1,338,050 $1,389,550 $1,441,000 $1,492,450 $1,543,900 $1,595,400

$1,183,649 $1,235,149 $1,286,599 $1,338,049 $1,389,549 $1,440,999 $1,492,449 $1,543,899 $1,595,399 $1,646,849

$566,100

$617,549

$14

$17

$617,550

$668,999

$14

$17

$20

$23

$669,000

$720,499

$14

$17

$20

$23

$26

$29

$720,500

$771,949

$14

$17

$20

$23

$26

$29

$32

$35

$771,950

$823,399

$14

$17

$20

$23

$26

$29

$32

$35

$38

$41

$823,400

$874,899

$22

$17

$20

$23

$26

$29

$32

$35

$38

$41

$874,900

$926,349

$20

$25

$20

$23

$26

$29

$32

$35

$38

$41

$926,350

$977,799

$18

$23

$28

$23

$26

$29

$32

$35

$38

$41

$977,800

$1,029,249

$25

$21

$26

$31

$26

$29

$32

$35

$38

$41

$1,029,250

$1,080,749

$28

$26

$22

$27

$32

$27

$30

$33

$36

$39

$1,080,750

$1,132,199

$18

$28

$26

$22

$27

$32

$27

$30

$33

$36

$1,132,200

$1,183,649

$18

$28

$26

$22

$27

$32

$27

$30

$33

$1,183,650

$1,235,149

$18

$28

$26

$22

$27

$32

$27

$30

$1,235,150

$1,286,599

$18

$28

$26

$22

$27

$32

$27

$1,286,600

$1,338,049

$18

$28

$26

$22

$27

$32

$1,338,050

$1,389,549

$18

$28

$26

$22

$27

$1,389,550

$1,440,999

$18

$28

$26

$22

$1,441,000

$1,492,449

$18

$28

$26

$1,492,450

$1,543,899

$18

$28

$1,543,900

$1,595,399

$18

$1,595,400

$1,646,849

Combined wages between $1,132,200 and $1,646,849

Higher earner’s wages

$1,646,850 $1,698,300 $1,749,800 $1,801,250 $1,852,700 $1,904,200 $1,955,650 $2,007,100 $2,058,550 $2,110,050

$1,698,299 $1,749,799 $1,801,249 $1,852,699 $1,904,199 $1,955,649 $2,007,099 $2,058,549 $2,110,049 $2,161,527

$823,400

$874,899

$43

$46

$874,900

$926,349

$43

$46

$49

$52

$926,350

$977,799

$43

$46

$49

$52

$55

$58

$977,800

$1,029,249

$43

$46

$49

$52

$55

$58

$61

$64

$1,029,250

$1,080,749

$42

$45

$48

$51

$54

$57

$60

$63

$466

$875

$1,080,750

$1,132,199

$39

$42

$45

$48

$51

$54

$57

$60

$463

$875

$1,132,200

$1,183,649

$36

$39

$42

$45

$48

$51

$54

$57

$460

$872

$1,183,650

$1,235,149

$33

$36

$39

$42

$45

$48

$51

$54

$457

$870

$1,235,150

$1,286,599

$30

$33

$36

$39

$42

$45

$48

$51

$454

$867

$1,286,600

$1,338,049

$27

$30

$33

$36

$39

$42

$45

$48

$451

$864

$1,338,050

$1,389,549

$32

$27

$30

$33

$36

$39

$42

$45

$448

$861

$1,389,550

$1,440,999

$27

$32

$27

$30

$33

$36

$39

$42

$445

$858

$1,441,000

$1,492,449

$22

$27

$32

$27

$30

$33

$36

$39

$442

$855

$1,492,450

$1,543,899

$26

$22

$27

$32

$27

$30

$33

$36

$439

$852

$1,543,900

$1,595,399

$28

$26

$22

$27

$32

$27

$30

$33

$436

$849

$1,595,400

$1,646,849

$18

$28

$26

$22

$27

$32

$27

$30

$433

$846

$1,646,850

$1,698,299

$18

$28

$26

$22

$27

$32

$27

$430

$843

$1,698,300

$1,749,799

$18

$28

$26

$22

$27

$32

$427

$840

$1,749,800

$1,801,249

$18

$28

$26

$22

$27

$432

$837

$1,801,250

$1,852,699

$18

$28

$26

$22

$427

$842

$1,852,700

$1,904,199

$18

$28

$26

$422

$837

$1,904,200

$1,955,649

$18

$28

$426

$832

$1,955,650

$2,007,099

$18

$428

$836

$2,007,100

$2,058,549

$418

$837

$2,058,550

$2,110,049

$208

$428

$2,110,050

$2,161,527

$13

Combined wages between $1,646,850 and $2,161,527

Higher earner’s wages

Note:

These charts do not account for additional withholding in the following instances:

• a married couple with both spouses working, where one spouse’s wages are more

spouse’s wages are also more than $1,080,763.50 but less than $2,161,257;

• married taxpayers with only one spousethan working, one job, and with that wages spouse from works each more job under

combined wages from all jobs is over $2,161,257.

If you are in one of these situations and you would like to request an additionalTax

Department for assistance

Need help?

on page 6).(see

Need help?

Telephone assistance

Automated income tax

refund status:

(518) 457-5149

Personal Income Tax

Information Center: (518)

To order forms and publications: (518) 457-5431

Text Telephone (TTY) Hotline

(for persons with

hearing and speech disabilities using a TTY)

: (518) 485-5082

Visit our Web site at

www.tax.ny.gov

• get information and manage your

• check for new online services and

Page 6

of 7

IT-2104

(2013)

$102,900

$123,500

$144,100

$164,650

$185,250

$226,400

$267,600

$308,750

$360,250

$411,700

$463,150

$123,499 $144,099

$164,649

$185,249

$226,399

$267,599

$308,749

$360,249

$411,699

$463,149

$514,599

$51,450

$72,049

$12

$17

$72,050

$92,599

$12

$19

$25

$92,600

$113,199

$16

$22

$25

$26

$113,200

$123,499

$11

$18

$20

$24

$27

$123,500

$133,799

$14

$17

$21

$27

$133,800

$144,099

$11

$14

$18

$27

$25

$144,100

$154,349

$11

$15

$27

$23

$154,350

$164,649

$13

$26

$24

$20

$164,650

$185,249

$10

$24

$27

$21

$23

$185,250

$226,399

$20

$28

$26

$23

$17

$226,400

$267,599

$15

$23

$18

$17

$12

$267,600

$308,749

$14

$21

$15

$16

$308,750

$360,249

$15

$21

$14

$360,250

$411,699

$15

$21

$411,700

$463,149

$15

$463,150

$514,599

Combined wages between $102,900 and $514,599

Higher wage

$514,600

$566,100

$617,550

$669,000

$720,500

$771,950

$823,400

$874,900

$926,350

$977,800 $1,029,250 $1,080,750

$566,099 $617,549

$668,999 $720,499 $771,949

$823,399

$874,899 $926,349 $977,799 $1,029,249 $1,080,749 $1,132,199

$267,600

$308,749

$308,750

$360,249

$16

$360,250

$411,699

$14

$16

$411,700

$463,149

$21

$14

$16

$463,150

$514,599

$15

$21

$14

$16

$514,600

$566,099

$15

$21

$14

$16

$214

$432

$566,100

$617,549

$15

$21

$14

$16

$214

$432

$617,550

$668,999

$15

$21

$14

$16

$214

$432

$669,000

$720,499

$15

$21

$14

$16

$214

$432

$720,500

$771,949

$15

$21

$14

$16

$214

$432

$771,950

$823,399

$15

$21

$14

$16

$214

$432

$823,400

$874,899

$15

$21

$14

$222

$432

$874,900

$926,349

$15

$21

$220

$440

$926,350

$977,799

$15

$228

$438

$977,800

$1,029,249

$222

$445

$1,029,250

$1,080,749

$111

$233

$1,080,750

$1,132,199

$13

Combined wages between $514,600 and $1,132,199

Higher wage

Part 5 –

These charts are only for single taxpayers and head of household taxpayers

wages are between $102,900 and $2,161,527.

Enter the additional withholding dollar amount on line 3.

The additional dollar amount, as shown below, is accurate for a need weekly to payroll.

adjust these dollar amount(s). For example, if you are paid biweekly, you

Privacy notifcation

The CommissionerTaxation of and Finance may collect and maintain personal

information pursuantYork StateT toax theLaw ,New 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,Tax Law under.

the

This information is maintained by the ManagerTax

of Document Management, NYS

Department,A Harriman W

Campus,Albany 12227; NY

telephone (518) 457-5181.

(Part 5 continued on page 7)

IT-2104

(2013)

Page 7

of 7

$1,132,200 $1,183,650 $1,235,150 $1,286,600 $1,338,050 $1,389,550 $1,441,000 $1,492,450 $1,543,900 $1,595,400

$1,183,649 $1,235,149 $1,286,599 $1,338,049 $1,389,549 $1,440,999 $1,492,449 $1,543,899 $1,595,399 $1,646,849

$566,100

$617,549 $455

$477

$617,550

$668,999 $455

$477

$499

$522

$669,000

$720,499 $454

$477

$499

$522

$544

$567

$720,500

$771,949 $455

$477

$499

$522

$544

$567

$589

$612

$771,950

$823,399 $455

$477

$499

$522

$544

$567

$589

$612

$634

$657

$823,400

$874,899 $455

$477

$499

$522

$544

$567

$589

$612

$634

$657

$874,900

$926,349 $454

$477

$499

$522

$544

$567

$589

$612

$634

$657

$926,350

$977,799 $462

$477

$499

$522

$544

$567

$589

$612

$634

$657

$977,800

$1,029,249 $460

$485

$499

$522

$544

$567

$589

$612

$634

$657

$1,029,250

$1,080,749 $261

$277

$301

$316

$338

$360

$383

$405

$428

$450

$1,080,750

$1,132,199

$38

$66

$81

$106

$120

$143

$165

$188

$210

$233

$1,132,200

$1,183,649

$13

$38

$66

$81

$106

$120

$143

$165

$188

$210

$1,183,650

$1,235,149

$13

$38

$66

$81

$106

$120

$143

$165

$188

$1,235,150

$1,286,599

$13

$38

$66

$81

$106

$120

$143

$165

$1,286,600

$1,338,049

$13

$38

$66

$81

$106

$120

$143

$1,338,050

$1,389,549

$13

$38

$66

$81

$106

$120

$1,389,550

$1,440,999

$13

$38

$66

$81

$106

$1,441,000

$1,492,449

$13

$38

$66

$81

$1,492,450

$1,543,899

$13

$38

$66

$1,543,900

$1,595,399

$13

$38

$1,595,400

$1,646,849

$13

Combined wages between $1,132,200 and $1,646,849

Higher wage

$1,646,850 $1,698,300 $1,749,800 $1,801,250 $1,852,700 $1,904,200 $1,955,650 $2,007,100 $2,058,550 $2,110,050

$1,698,299 $1,749,799 $1,801,249 $1,852,699 $1,904,199 $1,955,649 $2,007,099 $2,058,549 $2,110,049 $2,161,527

$823,400

$874,899 $679

$702

$874,900

$926,349 $679

$702

$724

$747

$926,350

$977,799 $679

$702

$724

$747

$769

$791

$977,800

$1,029,249 $679

$702

$724

$747

$769

$791

$814

$836

$1,029,250

$1,080,749 $473

$495

$518

$540

$563

$585

$608

$630

$652

$262

$1,080,750

$1,132,199 $255

$278

$300

$323

$345

$368

$390

$413

$435

$457

$1,132,200

$1,183,649 $233

$255

$278

$300

$323

$345

$368

$390

$412

$435

$1,183,650

$1,235,149 $210

$233

$255

$278

$300

$323

$345

$368

$390

$412

$1,235,150

$1,286,599 $188

$210

$233

$255

$278

$300

$323

$345

$368

$390

$1,286,600

$1,338,049 $165

$188

$210

$233

$255

$278

$300

$323

$345

$368

$1,338,050

$1,389,549 $143

$165

$188

$210

$233

$255

$278

$300

$323

$345

$1,389,550

$1,440,999 $120

$143

$165

$188

$210

$233

$255

$278

$300

$323

$1,441,000

$1,492,449 $106

$120

$143

$165

$188

$210

$233

$255

$278

$300

$1,492,450

$1,543,899

$81

$106

$120

$143

$165

$188

$210

$233

$255

$278

$1,543,900

$1,595,399

$66

$81

$106

$120

$143

$165

$188

$210

$233

$255

$1,595,400

$1,646,849

$38

$66

$81

$106

$120

$143

$165

$188

$210

$233

$1,646,850

$1,698,299

$13

$38

$66

$81

$106

$120

$143

$165

$188

$210

$1,698,300

$1,749,799

$13

$38

$66

$81

$106

$120

$143

$165

$188

$1,749,800

$1,801,249

$13

$38

$66

$81

$106

$120

$143

$165

$1,801,250

$1,852,699

$13

$38

$66

$81

$106

$120

$143

$1,852,700

$1,904,199

$13

$38

$66

$81

$106

$120

$1,904,200

$1,955,649

$13

$38

$66

$81

$106

$1,955,650

$2,007,099

$13

$38

$66

$81

$2,007,100

$2,058,549

$13

$38

$66

$2,058,550

$2,110,049

$13

$38

$2,110,050

$2,161,527

$13

Combined wages between $1,646,850 and $2,161,527

Higher wage