Hubbell Policies

Employee Name: Joe Traveler Primary Work State: STATE Reporting Period: DATE - DATE Today’s Date: DATE

TRAVEL SUMMARY

Based on your Concur travel data, you have traveled XX days to STATE during the reporting period noted above. Effective DATE your current year state taxable income and state withholding will be allocated to account for the days you have traveled outside of your Primary Work State. As a result, your current year W-2 will show income and taxes withheld for your Primary Work State and the state(s) where you exceeded the 30 day rule. See example attached. Listed below are your options for your withholding adjustments: Option A Total days XX traveled to STATE over (work days in the quarter) 65 = ratio to be withheld starting DATE. (Applicable if you expect number of travel days to be consistent for each quarter throughout the current year) Option B Total days XX traveled to STATE over (work days in the year) 260 = ratio to be withheld starting DATE. (Applicable if your travel has largely been completed for the current year) Please complete the section below as well as the attached state withholding form W4 and send them to Dawn Rising in the Corporate Tax Department by DATE. In the event the company fails to withhold appropriate taxes, I understand that it is still my responsibility to correctly report wages earned to the correct state and that failure to report could result in penalties. Important Notes: • If we do not receive your elected option by DATE, you will default to Option A on DATE. • If we do not receive your state withholding form W4, your tax elections will be defaulted to Single, with 0 exemptions. NOTE: This data will be reviewed each quarter and the ratios in each option will be adjusted if necessary.

Circle withholding option selected - Option A Option B

Employee Signature Date

Mobile Employees will be required to file a personal income tax return with any state for which payroll taxes have been withheld during the current year. To assist in the filing of multiple state returns, Hubbell will provide $250 cash allowance for each additional state tax return that the Mobile Employees will need to file. This benefit, which is taxable, is intended to offset the cost of preparing additional state tax returns. This payment will be processed in February each year based on prior year reporting. It will be processed as a separate payment to the Mobile Employee and will be taxed at supplemental withholding rates.

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