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First Name and Middle Initial: required |
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Last Name: required |
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Home address (number and street or rural route) required |
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City or Town, State, and Zip Code required |
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Social Security Number: required |
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Marital Status: required |
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| Section 1 - Determining Minnesota Allowance |
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| Section 2 — Exemption From Minnesota Withholding |
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Minnesota Allowances (Step F from above or Step 10 of the Itemized Deductions Worksheet.) required |
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Additional Minnesota withholding you want deducted each pay period (see instructions) required |
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Daytime Phone required |
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