FORM W-4P
Withholding Certificate For
Pension or Annuity Payments
RS 4531
(Rev. 3/19)
Please type or print clearly
in blue or black ink
NYSLRS ID Social Security Number
Retirement System [check one]
Employees’ Retirement System (ERS)
Police and Fire’ Retirement System (PFRS)
PLEASE PRINT CLEARLY USING CAPITAL LETTERS, USE ONLY BLUE OR BLACK INK, STAY WITHIN BOXES. LEAVE BLANK BOXES
BETWEEN WORDS AND NUMBERS
Retirement Number (if known)
Registration Number (if known)
Last Name First Name M.I.
Street
A
ddress 1
Street
A
ddress 2
City Sta
te Zip Co
de
Complete as applicable below, please sign and date where indicated, form is not valid unless signed.
Section 1
I DO NOT want to have Federal Income Tax withheld from my monthly benefit.
(DO NOT complete section 2 or 3)
-OR-
Section
2
I want to have Federal Income Tax calculated and withheld using the Federal Tax Withholding Tables
Marital Status (Check one): Single/Widow(er)
Married Married, but withhold at higher Single rate
Received Date
- -
Total number of allowances (exemptions) I wish to claim
(example for 3 exemptions)
0 3
(DO NOT complete section 1; Section 3 is optional)
Section 3
Please withhold an additional
amount of
$ each month.
(DO NOT
complete
section 1;
MUST complete
Section 2;
you may
not enter
an amount here
without completing
Section
2)
, .
Mail completed form to address above Attention Tax Unit Mail Drop 4-2
Signature_________________________________________________ Date ________________________________
Personal Privacy Protection Law
The Retirement System is required by law to maintain records to determine eligibility for and calculate benefits. Failure to provide information may interfere with the timely
payment of benefits. The System may be required to provide certain information to participating employers. The official responsible for record maintenance is the Director of
Member and Employer Services, NYS and Local Retirement System, Albany, NY 12244; call toll-free at 1-866-805-0990 or 518-474-7736 in the Albany Area.
*Social Security Disclosure Requirement
In accordance with the Federal Privacy Act of 1974, you are hereby advised that disclosure of your Social Security account number is mandatory pursuant to Sections 11, 34,
311 and 334 of the Retirement and Social Security Law. The number will be used in identifying retirement records and in the administration of the Retirement System.
RS 4531 (Rev. 03/19) Page 1 of 1
*03/19RS4531*
