FEDERAL WITHHOLDING TAXES AT 28% FOR ONE PAY ONLY



PAYROLL

SUPPLEMENTAL TAX RATE

REQUEST FORM

|NAME: |EMPLOYEE ID #: |

|      |      |

I request to have my supplemental wages taxed at the current supplemental rate (25% in 2011) for Federal Tax Withholding on the pay date of _____     ___________only,

when I expect to receive supplemental wages for __     __

(Describe reason for extra pay)

Additional Information:

1. This rate will apply only to federal taxes calculated on the gross supplemental wage amount.

2. This rate will not affect the state tax or the FICA tax.

|SIGNATURE: |DATE: |

| |      |

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