Use this form to notify your pension
administrator or other payer whether
income tax is to be withheld, and on what
basis.
Am I required to fi le Form VA-4P? Yes. You
MUST fi le Form VA-4P with your pension or
annuity payer before your payments begin.
If you do not fi le Form VA-4P, your payer
is required to withhold Virginia income tax
from your payments as if you had claimed
zero exemptions.
Can I elect “no withholding”?. You may use
PERSONAL EXEMPTION WORKSHEET
1. Enter “1” for yourself...................................................................................................
2. If you are married and your spouse is not claimed on his or her own certifi cate,
enter “1” ......................................................................................................................
3. Enter the number of dependents you will claim on your income tax return
(do not include your spouse) ......................................................................................
4. Subtotal of Personal Exemptions - add lines 1 - 3 ...................................................................................... ___________________
5. Exemptions for age
a) It you will be 65 or older on January 1, enter “1” .................................................
b) If you claimed an exemption on line 2 above and your spouse will
be 65 or older on January 1, enter “1”.................................................................
6. Exemptions for blindness
a) If you are legally blind enter “1” ...........................................................................
b) It you claimed an exemption on line 2 above and your spouse is
legally blind, enter “1 “ .........................................................................................
7. Subtotal of Age and Blindness Exemptions - add lines 5 & 6 ..................................................................... ___________________
8. Total exemptions (add lines 4 and 7) ...................................................................................................... ___________________
--------------------------------------- CUT HERE AND SEND TO THE PAYER OF YOUR PENSION OR ANNUITY--------------------------------------
FORM VA-4P Virginia Withholding Exemption Certifi cate for
Recipients of Pension and Annuity Payments
Complete the applicable lines below:
1. If subject to withholding, enter the number of exemptions claimed on
(a) Subtotal of Personal Exemptions - line 4 of the Personal Exemption Worksheet .................................. ___________________
(b) Subtotal of Age and Blindness Exemptions - line 7 of the Personal Exemption Worksheet .................. ___________________
(c) Total Exemptions - line 8 of the Personal Exemption Worksheet ........................................................... ___________________
2. Enter the amount of additional withholding requested (see instructions) .................................................... ___________________
3. Enter the amount of voluntary withholding requested (see instructions) ..................................................... ___________________
4. I certify that I am not subject to Virginia withholding, either because I have elected “no withholding”
for federal purposes, or I meet the conditions for exemption set forth in the instructions for
Form VA-4P. ........................................................................................................................ (Check here.) j
Signature _______________________________________________________________________ Date _______________________________
FORM VA-4P INSTRUCTIONS
VIRGINIA DEPARTMENT OF TAXATION
WITHHOLDING EXEMPTION CERTIFICATE FOR RECIPIENTS OF
PENSION AND ANNUITY PAYMENTS
this form to elect “no withholding” if you have
made a similar election for
federal purposes, or if you meet any of
the conditions listed in the instructions for
Line 4 of Form VA-4P on the reverse side
of this sheet.
What if I have other income? If you have
income from other sources which is not
subject to Virginia income tax withholding,
you should consider making estimated tax
payments on form 760-ES, or requesting
that an additional amount of tax be withheld
from your pension or annuity payment. You
can download Form 760-ES or electronically
fi le your estimated payment on our website,
www.tax.virginia.gov. You may also order
Form 760-ES by calling (804) 440-2541 or
contacting your local commissioner of the
revenue.
How do I complete Form VA-4P?
Be sure to read the instructions on the
reverse side of this page carefully before
completing Form VA-4P. If you need
assistance, you may contact the Department
of Taxation at (804) 367-8037.
Your Social Security Number Name
Street Address
City State Zip Code
2601062 Rev. 11/07
