Form 499 R-4 Government of Puerto Rico

Rev. June 30, 11 Department of Treasury

CERTIFICATE OF EXEMPTION FROM WITHHOLDING
READ THE INSTRUCTIONS ON THE BACK BEFORE COMPLETING THIS EXEMPTION CERTIFICATE FOR WITHHOLDING
Fill out and submit this form to your employer. Otherwise, he will be required by the Internal Revenue Code for a New Puerto Rico (Code) to withhold your
contribution on income without taking into account personal exemption, dependent exemption, and deduction allowance.
CHANGES IN PERSONAL EXEMPTION, THE NUMBER OF DEPENDENTS OR THE GRANTING OF DEDUCTIONS REQUIRE THE REPLACEMENT OF THIS CERTIFICATE.
FOR EMPLOYEE USE
Employee name Employee's social security number
Rosendo Telles Rosario 584-47-0850
Spouse name Spouse's social security number
Carol Ortega Gonzalez 582-37-4124
Residential address Postal address
House F-12 Urbanization Views of Naguabo Bo. Duque Bzn. 2168 Naguabo PR 00718
Mark here if your annual gross salary is not greater than $20,000. If you want your employer to withhold tax on your wages, complete Part D.
Otherwise, please sign this Certificate.
Mark here if you are claiming the provisions of the Military Spouses Residency ReliefAct. (See instructions)
Check here if you opt for the optional calculation of the contribution in the case of married individuals living together and filing a joint return. (See instructions)
A. PERSONAL EXEMPTION Complete Half None
(lower retention) (higher retention)
1. Individual taxpayer
2. Married person
3. Additional personal exemption for veterans
B. EXENCION POR DEPENDIENTES:Número de Dependientes
Complete Exemption Shared Custody
C. CONCESSION FOR DEDUCTIONS
1. CONCESSION FOR SPECIAL DEDUCTION FOR CERTAIN INDIVIDUALS (See instructions) ....... Complete None
2. CONCESSION FOR DEDUCTIONS (OPTIONAL):
Mortgage interests 00
Donations 00
(c) Medical expenses 00
Interest on student loans at the university level 00
Contributions to government pension or retirement systems (See instructions) .................................................. 00
Contributions to individual retirement accounts 00
(g) Educational Contribution Account 00
(h) Contributions to health savings accounts 00
Loss of your primary residence due to unforeseen causes 00
Loss of movable property due to certain fortuitous causes. 00
Total de deducciones 00
3. Number of concessions based on deductions (Line 2(k) between $500) ...........................................................................
4. Concessions you wish to claim (Can be less than or equal to line 3) ................................................................................
If you are a government employee, please check this box to indicate if you participate in any of these programs (see instructions):
Supplemental Retention Plan for Retirement
Retirement Savings Account Program (Indicate the percentage you chose as contribution ______%)
D. ELECTION FOR ADDITIONAL WITHHOLDING
I authorize my employer to withhold from each payroll period the amount of $_______ or _______% of my salary in addition to the contribution that
It is required to deduct and withhold according to the provisions of Section 1062.01 of the Code. (See instructions)
Oath
I declare under penalty of perjury that I have examined this form, and that to the best of my knowledge, the information provided herein is true and correct.
and complete. I also certify that the personal exemption, the exemption for dependents, and the allowance for deductions that I claim here, for the purposes of the
wage garnishment does not exceed the amount that I am entitled to claim on the income tax return, as provided by the Code.

_________________
Employee signature Date
Conservation Period: Six (6) years
 INSTRUCTIONS
The Exemption Certificate for Withholding (Form 499 R-4) is the document in Line 2 - You have the option that they be considered in the calculation of the withholding, the
the employee informs the employer of their personal exemption, exemption for dependents deductions you can claim on your income tax return. These
and the concession for deductions. These three factors are taken into consideration for they will reduce the amount of contribution that the employer will withhold from your salaries. If you do not wish
determine the income contribution that will be withheld from your salary. that they are considered in the calculation, do not complete this line.
Complete the top part of the form, indicating your name, social security number, Note in lines 2(a) to 2(j) the amount of these deductions that you estimate will have.
residential address and postal address. right to claim on your form. These are subject to the limits and requirements provided in
Section 1033.15 of the Code.
If your annual gross salary does not exceed $20,000, it will not be subject to withholding.
at the origin. However, you can choose for your employer to carry out the withholding If he is married and opts for optional computation, he will determine the number of concessions.
of income contribution according to the amount or percentage indicated distributing the deductions between both spouses. In the case of mortgage interest,
in Part D of this Certificate. donations, medical expenses, and the losses of their primary residence and personal property
due to certain fortuitous causes, include 50% of each deduction. In the case of
Under the Military Spouses Residency Relief Act (MSRRS), if you are the spouse of a contributions to governmental pension or retirement systems, Individual Retirement Accounts,
active service member who was transferred under military orders to a new Educational Contribution Accounts, Health Savings Accounts and interest on loans
military station in any of the states, possessions, or territories of the United States or student fees, include the amount that corresponds to you individually.
the District of Columbia may maintain its original residence or domicile for purposes
of taxation. Indicate if you adhere to this option so that the employer is not Line 2(e) - If you are a government employee, you should consider the pension system.
obliged to withhold income tax for purposes of Puerto Rico. No the pension fund to which he contributes, if any:
however, you may be subject to the payment of estimated federal tax or the
perform federal, local, or state withholding, as applicable. ·
state, possession, or territory for which he chose to maintain his residence or the employer mayIf contributions are made to the government pension or retirement system, it must
consider 8.275% of your annual salary.
If you are married, include your spouse's name and social security number, and indicate if
it accepts the optional computation of the contribution in the case of married people living · Ifmonthly
you opted for the supplemental retirement plan, then you will consider 5.775% of your
compensation up to $550 and 8.275% of the monthly compensation in excess of
jointly and submit a joint form (optional computation), as provided by the Section that amount (raised to an annual basis).
1021.03 of the Internal Revenue Code for a New Puerto Rico (Code).
PART A - PERSONAL EXEMPTION · On the other hand, if he is a government employee who makes contributions through the
Retirement Savings Account Program must consider 8.275%, 9%,
9.5% or 10% (as you have chosen) of your annual salary.
Indicate with an 'X' your option regarding the personal exemption that your employer
you must consider when determining the amount of income contribution that there will beIf you are a government employee who works for an agency whose payroll
to detain him. is processed by the Department of Treasury, do not consider your contributions to
pension or retirement system in this line. This deduction will be considered
Line 1 - An individual taxpayer (single person, married person who has provided a marriage contract)
automatically in the calculation of the withholding.
prenuptial agreements with total separation of assets or divorced from their spouse
You may consider or not your personal exemption for the calculation of the withholding. If you wish Line 3 - Divide the total of line 2(k) by $500. Any resulting fraction of the
that their personal exemption is taken into account, make a mark in the column previous division in excess of 50% will be treated as an additional concession.
titled 'Complete'. On the other hand, if you choose not to consider the personal exemption,
you must make a mark in the column titled 'None'. An individual taxpayer Line 4 - From the amount determined in line 3, indicate the concessions you wish.
cannot choose to consider the "Half" of their personal exemption. to complain. If you file as a married taxpayer and do not opt for the optional computation, you
and their spouse have the right to divide the total concessions as they wish, but to
Line 2 - A marriage is entitled to only one personal exemption, which prevents that complete concession base. However, any concession considered by one of
both spouses can simultaneously consider the entirety of it. If you are a the spouses cannot be considered by the other.
married couple and both spouses receive wages subject to withholding, then
They will need to agree on how they will consider their personal exemption. PART D - ELECTION FOR ADDITIONAL WITHHOLDING
and they will make a mark in the corresponding column. If they determine that one of the
spouses will consider the full personal exemption, this will make a mark on the Any employee can choose for their employer to withhold an additional amount from the
column titled "Complete." In such a case, the other spouse must make the mark in the required under Section 1062.01(e) of the Code. Under no circumstances, this option will be
column titled "None". If you have agreed with your spouse to distribute yourselves admitted for an amount less than the contribution determined according to the tables of
equal personal exemption, indicate it by marking the column retention that in harmony with the tax rates established by the Code approves the
titled 'Half'. If you do not wish to consider the personal exemption, make the mark on the Secretary. Furthermore, this option can be exercised by any employee whose gross annual salary does not
column titled "None." exceed $20,000 and choose to have withholding taken from that salary.
If he is married and opts for the optional calculation, the personal exemption will be considered Oath
at a rate of 50% for each spouse. Therefore, each spouse can choose to
consider the full personal exemption or none in relation to this 50%. You declare under penalty of perjury that you have examined this form, and that according to your
better criterion, the information that appears in it is true, correct, and complete.
Line 3 - Every veteran has the right to have personal exemption considered.
additional. The veteran may consider their complete additional personal exemption or not SIGNATURE
consider it.
Any employee who completes this form must sign it and indicate the date.
PART B - DEPENDENT EXEMPTION
PENALTIES
Indicate the number of dependent persons that will be considered for the calculation of
the withholding. These must be the same that you can claim as dependents in your Any employee required to provide their employer with a certificate of exemption for the
income contribution form. Indicate separately in the box retention, that voluntarily provides false or fraudulent information, or that voluntarily
corresponding, the children for whom he has the right to joint custody and has not stop providing information that would require an increase in the contribution to be withheld,
the exemption granted. In these cases, only 50% of the exemption will be considered. will incur in a less serious offense in accordance with the provisions of Section 6041.08 of the Code.

If you are an employee opting for optional computation, your exemption for In the case of employees who choose to consider the concession for deductions provided in the
dependents will be 50% of the total amount provided by Section 1033.18(b) of the Code. Section 1062.01(c)(2)(A)(ii) of the Code, in addition to the aforementioned criminal penalty, if
since in these cases each spouse will have the right to consider only half of the 70% of the contribution attributable to income from salaries subject to withholding
exemption for dependents, as established by Section 1021.03 of the Code. the contribution withheld at source on said income exceeds, it will be added to the contribution
the lesser of: (1) an amount equal to such excess, or (2) an amount equal to 18% of the total for
The Code stipulates that any employer who receives a certificate from any employee the contribution thus determined exceeds the retained contribution.
exemption in which the number of dependents exceeds 8, must submit to the
Treasury Secretary a copy of this certificate, as well as a copy of any INSTRUCTIONS TO THE EMPLOYER
written statement received from the employee to support the information contained in the
certificate. The employer will consider the information provided by the employee in this Certificate of
Exemption regarding your personal exemption, exemption for dependents, and grant
PART C - GRANTING DEDUCTIONS for deductions to carry out the withholding according to the Employer's Manual on
Withholding at the Source of the Income Contribution in the Case of Salaries for the Year
You have the right to certain concessions based on deductions, which your corresponding contribution.
the employer must take into account when determining the amount of contribution on
income that must be withheld. If the employee's gross annual salary does not exceed $20,000, such salaries are not subject to
the withholding at the source, unless the employee has completed the choice for it to be
Line 1 - The number of concessions under the special deduction for certain individuals make the additional withholding.
is subject to the limits and requirements provided by Section 1033.16 of the Code. This
deduction will be available for those individuals whose gross income does not exceed If the employee adheres to the provisions of MSRRA, no withholding will be performed on the
$20,000, stipulating that for every dollar of gross income in excess of $20,000, the origin on wages for purposes of Puerto Rico. However, it may be subject to
The allowable deduction will be reduced by fifty cents until it reaches zero. withhold federal taxes as determined by the Internal Revenue Service.
If you choose for the special deduction to be considered, please mark the box. If the number of dependents exceeds 8, submit a copy of this Certificate to the Office.
titled "Complete". On the other hand, if you choose not to consider the deduction of the Tax Audit, as well as a copy of any written statement received from the employee
special, should make a mark in the box titled "None". to support the information contained in the certificate.