FIACCT 11-02_00 Payroll – Utah Income Tax Withholding – Authorization Form FI 41

Effective: October 1, 1990
Revised: May 17, 2007
Reviewed: September 1, 2009

Purpose

This policy provides instructions for an employee to request, change, or cancel additional Utah State income tax withholdings from his/her pay.

Policy

A. Employees may request additional Utah State income taxes be withheld from their payroll warrants.

B. A completed, original Authorization for Voluntary Additional Utah Income Tax Withholding, Form
FI 41, may be submitted to the Division of Finance Payroll Section for:
Requesting additional withholdings
Changing current amounts of additional withholdings
Canceling any current amounts of additional withholdings
Form FI 41 is available on the Division of Finance Web site at www.finance.utah.gov.

C. The Division of Finance Payroll Section may enter new requests, changes, and/or cancellations of
additional Utah State income tax withholdings.

Changes made to employee additional Utah State income tax withholdings will be made on the Payroll System no later than the third (3rd) payday following receipt of the Authorization for Voluntary Additional Utah State Income Tax Withholding, Form FI 41, at the Division of Finance Payroll Section.

D. The employee is responsible to verify that the requested changes have been made on the payroll warrant. Any discrepancies should be brought to the immediate attention of the department payroll/personnel staff.

Procedures

Responsibility

Action

Employee

Complete the Authorization for Voluntary Additional Utah Income Tax Withholding, Form FI 41.
Complete and submit the form to the Division of Finance, Payroll
Section.

Division of Finance

Enter new or changed information from the employee’s Voluntary Additional Utah Income Tax Withholding, Form FI 41, on the Payroll System.

Instructions for Entry

Field

Description

Check One:

New – Check this box to indicate an initial request for additional Utah State income tax withholding.

Change – Check this box to indicate a change in the current amount of additional Utah State income taxes being withheld.

Cancel – Check this box to indicate a request to cancel the current amount of additional Utah State income taxes being withheld.

Print or Type

Last Name, First Name, Initial

Enter the employee’s full name as it appears on the payroll warrant.

Social Security Number

Enter the employee’s Social Security Number.

$

Enter the amount of additional Utah State income taxes to be withheld from the employee’s payroll warrant.

Signature

The employee should sign the form.

Date

Enter the date the form is completed.