Form 89-350 Withholding Exemption Certificate Completed by employee; retained by employer.

Age 65 or older Husband Wife Single An additional exemption of $1 500 may be claimed by either taxpayer or spouse or both if either or both have reached the age of 65 before the close of the taxable year No additional exemption is authorized for dependents by reason of age Check applicable blocks on Line 5 Blind Husband Wife Single Enter $6 000 as exemption IF THE EMPLOYEE FAILS TO FILE AN EXEMPTION CERTIFICATE WITH HIS MISSISSIPPI EMPLOYEE'S WITHHOLDING EXEMPTION CERTIFICATE Single Individuals enter $6 000 on Line 1 TOTAL AMOUNT OF EXEMPTION CLAIMED Lines 1 through 5 "Exempt" on Line 8 You must attach a copy of the FederalForm DD 2058 and a copy of your Military Spouse ID Card tothis form so your employer can validate the exemption claim $ File this form with your $12 000 claimed by you in multiples of amount of your wages $500 See instructions 2(b) below (a) Single Individuals $6 000 (d) Dependents $1 500 (b) Married Individuals (Jointly) $12 000 (e) Age 65 and Over $1 500 (c) Head of family $9 500 (f) Blindness $1 500 (Check One) (d) An additional exemption of $1 500 may generally be claimed for each dependent of the taxpayer A dependent is any relative who receives chief support from the taxpayer and who qualifies as a dependent for Federal income tax purposes q p p p Head of family * A head of family may claim $1 500 for each 1 Single 1 The personal exemptions allowed: 2 Claiming personal exemptions: 2 Marital Status 3 Head of Family $ 3 Total Exemption Claimed: 30 DAYS AFTER ANY CHANGE IN YOUR EXEMPTION STATUS 5 Age and 8 If you meet the conditions set forth under the Service MemberResidencey Relief Act a head of A head of family is a single individual who maintains a home which is the principal place of abode for himself and at least one other dependent Single individuals qualifying as a head of family enter $9 500 on Line 3 If the taxpayer has more than one dependent additional exemptions are applicable See item (d) A NEW EXEMPTION CERTIFICATE MUST BE FILED WITH YOUR EMPLOYER WITHIN Add the amount of exemptions claimed in each category and enter the total on Line 6 This Additional dollar amount of withholding per pay period if $ advised agreed to by your employer amount will be used as a basis for withholding income tax under the appropriate withholding an addi An additional exemption of $1 500 may be claimed by either taxpayer or spouse or both if either or both are blind No additional exemption is authorized for dependents by reason of blindness Check applicable blocks on Line 5 Multiply number of blocks checked on Line 5 by $1 500 and enter amount of exemption claimed and 2(d)below and have a dependent living in the home with you See instructions 2(c) as head of family Multiply number of dependentsof Revenue should be Blindness BY THE Civil Relief as amended by the Military Spouses Residency CLAIM YOUR WITHHOLDING PERSONAL EXEMPTION claimed by you by $1 500 Enter amount claimed dependent dependent dependents excluding the one which qualifies youexemption the Department E TAX MUST BE W employee is believed to EMPLOYEE: Employee's Name SSN Employee's ResidenceMississippi Department of RevenueAddress Employee's Signature: Date: employer Otherwise you EMPLOYER: Enter $9 500 as exemption To qualifyas head of family you must be single Exemption from Mississippi for taxpayer and spouse who receives chief support from you and who qualifies as a dependent for Federal Form 89 350 12 8 1 000 (Rev 11/12) h dependent have claimed excess he one Head of Family HHELD I declare under the penalties imposed for filing false reports that the amount of exemption claimed on thiscertificate does not exceed the amount to which I am entitled or I am entitled to claim exempt status If the spouse is not employed enter $12 000 on Line 2(a) If the spouse is employed the exemption of $12 000 may be divided between taxpayer and spouse in any manner they choose in multiples of $500 For example the taxpayer may claim $6 500 and the spouse claims $5 500; or the taxpayer may claim $8 000 and the spouse claims $4 000 The total claimed by the taxpayer and spouse may not exceed $12 000 Enter amount claimed by you on Line 2(b) income tax purposes individuals m INSTRUCTIONS Married individuals are allowed a joint exemption of $12 000 Milit Military Spouses Multiply the number of blocks checked by $1 500 Enter the amount claimed must withhold Mississippi NCO E TAX MUST BE HHEL BY TH ON TOTA No exemption allowed for age or blindness No exemption allowed for age or blindnessfor dependents ON TOTAL P O Box 960 Number and Street City or Town State Zip CodeJackson MS 39205 PENALTIES ARE IMPOSED FOR WILLFULLY SUPPLYING FALSE INFORMATION Personal Exemption Allowed Amount ClaimedMarital Status Relief Act and have no Mississippi tax liability write should not include themselves or their spouse Married taxpayers may divide the number of their dependents between them in any manner they choose; for example a married couple has 3 children who qualify as dependents The taxpayer may claim 2 dependents and the spouse 1; or the taxpayer may claim 3 dependents and the spouse none Enter the amount of dependent exemption on Line 4 Spouse IS employed: Enter that part ofincome tax from the full Spouse NOT employed: Enter $12 000 tables Withholding You may claim $1 500 for each dependent* other than Keep this certificate with your records If the 4 Dependents