Request for Federal Income Tax Withholding from Sick Pay

• Issuer: Treasury Department
• Section: Treasury Department

Form W-4S

Department of the Treasury

Internal Revenue Service

Request for Federal Income Tax

Withholding From Sick Pay

Give this form to the third-party payer of your sick pay.

Go to www.irs.gov/FormW4S for the latest information.

OMB No. 1545-0074

2024

Your first name and middle initial Last name Your social security number

Home address (number and street or rural route)

City or town, state, and ZIP code

Claim or identification number (if any) . . . . . . . . . . . . . . . . . . . . . . . .

I request federal income tax withholding from my sick pay payments. I want the following amount to be

withheld from each payment. (See Worksheet below.) .................. $

Employee’s signature: Date:

Separate here and give the top part of this form to the payer. Keep the lower part for your records.

Worksheet (Keep for your records. Do not send to the IRS.)

1Enter amount of adjusted gross income that you expect in 2024 . . . . . . . . . . . . . 1

2

If you plan to itemize deductions on Schedule A (Form 1040), enter the estimated total of your deductions.

See Pub. 505 for details. If you don’t plan to itemize deductions, enter the standard deduction. (See the

instructions on page 2 for the standard deduction amount, including additional standard deductions for

age and blindness.) Note: There is no deduction for personal exemptions for 2024 . . . . . . . .

2

3Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . 3

4 Tax. Figure your tax on line 3 by using the 2024 Tax Rate Schedule X, Y-1, Y-2, or Z on page 2. Do not

use any tax tables, worksheets, or schedules in the 2023 Instructions for Form 1040 . . . . . . 4

5Credits (child tax and higher education credits, credit for child and dependent care expenses, etc.) . . 5

6Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Estimated federal income tax withheld or to be withheld from other sources (including amounts withheld

due to a prior Form W-4S) during 2024 or paid or to be paid with 2024 estimated tax payments . . . 7

8Subtract line 7 from line 6 . . . . . . . . . . . . . . . . . . . . . . . . . . 8

9 Enter the number of sick pay payments you expect to receive this year to which this Form W-4S will

apply ................................. 9

10

Divide line 8 by line 9. Round to the nearest dollar. This is the amount that should be withheld from

each sick pay payment. Be sure it meets the requirements for the amount that should be withheld, as

explained under Amount to be withheld below. If it does, enter this amount on Form W-4S above . . 10

General Instructions

Purpose of form. Give this form to the third-party payer of your sick

pay, such as an insurance company, if you want federal income tax

withheld from the payments. You aren’t required to have federal

income tax withheld from sick pay paid by a third party. However, if

you choose to request such withholding, Internal Revenue Code

sections 3402(o) and 6109 and their regulations require you to

provide the information requested on this form. Don’t use this form if

your employer (or its agent) makes the payments because employers

are already required to withhold federal income tax from sick pay.

Note: If you receive sick pay under a collective bargaining

agreement, see your union representative or employer.

Definition. Sick pay is a payment that you receive:

• Under a plan to which your employer is a party, and

• In place of wages for any period when you’re temporarily absent

from work because of your sickness or injury.

Amount to be withheld. Enter on this form the amount that you

want withheld from each payment. The amount that you enter:

• Must be in whole dollars (for example, $35, not $34.50).

• Must be at least $4 per day, $20 per week, or $88 per month

based on your payroll period.

• Must not reduce the net amount of each sick pay payment that

you receive to less than $10.

For payments larger or smaller than a regular full payment of sick

pay, the amount withheld will be in the same proportion as your

regular withholding from sick pay. For example, if your regular full

payment of $100 a week normally has $25 (25%) withheld, then $20

(25%) will be withheld from a partial payment of $80.

Caution: You may be subject to a penalty if your tax payments during

the year aren’t at least 90% of the tax shown on your tax return. For

exceptions and details, see Pub. 505, Tax Withholding and Estimated

Tax. You may pay tax during the year through withholding or

estimated tax payments or both. To avoid a penalty, make sure that

you have enough tax withheld or make estimated tax payments using

Form 1040-ES, Estimated Tax for Individuals. You may estimate your

federal income tax liability by using the worksheet above.

Sign this form. Form W-4S is not valid unless you sign it.

Statement of income tax withheld. After the end of the year, you’ll

receive a Form W-2, Wage and Tax Statement, reporting the taxable

sick pay paid and federal income tax withheld during the year.

These amounts are reported to the IRS.

Changing your withholding. Form W-4S remains in effect until you

change or revoke it. You may do this by giving a new Form W-4S or

a written notice to the payer of your sick pay. To revoke your

previous Form W-4S, complete a new Form W-4S and write

“Revoked” in the money amount box, sign it, and give it to the payer.

(continued on back)

For Paperwork Reduction Act Notice, see page 2. Cat. No. 10226E Form W-4S (2024)