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 le Form VA-4P? Yes.
You MUST file Form VA-4P with your
pension or annuity payer before your
payments begin. If you do not 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 this form to elect “no withholding”
PERSONAL EXEMPTION WORKSHEET
1. Enter “1” for yourself...................................................................................................
2. If you are married and your spouse is not claimed on his or her own certicate,
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) If 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) If 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 Certicate 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
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 760ES or requesting
that an additional amount of tax be withheld
from your pension or annuity payment. You
can download Form 760ES or electronically
le your estimated payment on our website,
www.tax.virginia.gov. You may also order
Form 760ES by calling (804) 367-8037 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. 04/19
