Annuitants Request For State Income Tax Withholding
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Annuitants Request For State Income Tax Withholding Form. This is a Indiana form and can be use in Department Of Revenue Statewide.
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Tags: Annuitants Request For State Income Tax Withholding, WH-4P, Indiana Statewide, Department Of Revenue
Form WH-4P
State Form 37365
(R2 / 8-08)
State of Indiana
Annuitant’s Request
for State and County Income Tax Withholding
(Please Type or Print Clearly)
Full Name_ _________________________________________________________________________
Social Security Number
Home Address (number and street)_ _____________________________________________________
City, State, and Zip code_______________________________________________________________
A.
Annuity contract claim or identification number. .................................................................................................. A. ________________
.
B.
Enter the amount of Indiana state tax to be withheld from each annuity or pension payment............................. B. $________________
C.
Enter your 2-digit county code
pension payment.................................................................................................................................................. C. $________________
D.
Total amount withheld: add line B plus line C (must be $10 or more).................................................................. D. $ ________________
and the amount of county tax to be withheld from each annuity or
I request voluntary income tax withholding from my annuity or pension payments.
_________________________________________________________
Signature of Annuitant
_ ___________________________
_
Date
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You may select any amount over $10.00 to be withheld from your annuity or pension payment. This withholding will be
reported to you on a W-2P at the end of each year as Indiana State and County Tax Withheld. Beginning January 1, 2009
an annuitant can request the payor of an annuity or pension to withhold a portion of their pension or annuity to offset their
county tax liability under IC 6-3.5.
A. Enter the Contract, Policy, or Account Number to which the request applies.
B. Enter an amount of state tax that you wish to have withheld from each check.
C. Enter your 2-digit county code and the amount of county tax to be withheld from each annuity or pension payment
D. Total amount withheld: add line B plus line C (must be $10 or more)
Send this form to the person or company paying your pension. Do not send this to the Department of Revenue.
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