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80024 / 2312 (Rev. 12/2019) ©2019 Ascensus, LLC
STATE INCOME TAX WITHHOLDING ELECTION
The term IRA will be used below to mean Traditional IRA, Roth IRA, and SIMPLE IRA, unless otherwise specified. This form may only
be used to supplement an IRA withdrawal form to make a state income tax withholding election.
PART 1. IRA INFORMATION
IRA OWNER
Name (First/MI/Last)
Social Security Number
Date of Birth Phone
Email Address
Account Number Suffix
ACCOUNT TYPE (Select one)
Traditional IRA Inherited Traditional IRA SIMPLE IRA
Roth IRA Inherited Roth IRA
FORM TYPE AND DATE (Complete and attach the supplemented form)
Form Type
Form Dated
PART 2. WITHHOLDING ELECTION
This form provides general information about state withholding requirements for IRA distributions. It is not intended to provide a complete overview of state
withholding rules and regulations. The information on this form is obtained from state revenue authorities, and every effort has been made to ensure its
accuracy. Because state tax laws are subject to constant change, often without prior notice, the accuracy of the information cannot be guaranteed beyond
the revision date of the form. Seek professional tax advice if you have questions regarding state withholding requirements that apply to your IRA distribution.
Refer to page 3 of this form for a summary of applicable State Income Tax Withholding Rules. Withholding is based on your state of residence, unless
noted otherwise.
ARKANSAS
Withhold 3.0%
Do not withhold
CALIFORNIA
Withhold 1.0%
Do not withhold
CONNECTICUT
Withhold 6.99%
Withhold $ based on my election on Form CT-W4P
Do not withhold based on my election on Form CT-W4P
DISTRICT OF COLUMBIA
Withhold 8.95%
Do not withhold
IOWA
Withhold 5.0% because I elected federal withholding
Do not withhold because I did not elect federal withholding
KANSAS
Withhold 5.0% regardless of my federal election
Do not withhold because I did not elect federal withholding
LOUISIANA
Withhold % (Not greater than 4.8%)
Do not withhold
MAINE
Withhold 5.0% because I elected federal withholding
Do not withhold because I did not elect federal withholding
MASSACHUSETTS
Withhold 5.0% because I elected federal withholding
Do not withhold because I did not elect federal withholding or I am
not required to pay Massachusetts income taxes
MICHIGAN
Withhold 4.25%
Withhold $ based on my election on Form MI W-4P
In addition to my election above, withhold an optional %
based on my election on Form MI W-4P
Do not withhold based on my election on Form MI W-4P
MISSOURI
Withhold 5.4%
Do not withhold
MONTANA
Withhold $
Do not withhold
NEBRASKA
Withhold % (Must be 5.0% or greater) regardless of my
federal election
Do not withhold because I did not elect federal withholding
NEW JERSEY
Withhold $ (Must be an even dollar amount)
Do not withhold
NORTH CAROLINA
Withhold 4.0%
Do not withhold based on my election on Form NC-4P
OKLAHOMA
Withhold 5.0% regardless of my federal election
Do not withhold because I did not elect federal withholding
OREGON
Withhold 8.0%
Do not withhold
VERMONT
Withhold 3.0% regardless of my federal election
Do not withhold because I did not elect federal withholding
WISCONSIN
Withhold $
Do not withhold
IRA
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80024 / 2312 (Rev. 12/2019) ©2019 Ascensus, LLC
OTHER
Use this section to elect a withholding rate not listed on page 1.
I file a tax return in (Name of state)
(Check and complete one box below.)
Withhold $
Withhold %
Do not withhold
PART 3. SIGNATURE
I have read and understand the applicable State Income Tax Withholding Rules on this form and agree to abide by those rules and conditions. All
decisions regarding this withholding are my own and I expressly assume the responsibility for any consequences that may arise from this withholding
election.
X
Signature of IRA Owner Date (mm/dd/yyyy)
IRA TRUSTEE OR CUSTODIAN INFORMATION: Name , Organization Number
Name of IRA Owner , Account Number
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80024 / 2312 (Rev. 12/2019) ©2019 Ascensus, LLC
STATE INCOME TAX WITHHOLDING RULES
GENERAL RULES
In most cases, state withholding applies to state residents only. In Maine, Massachusetts, Montana, Nebraska, Oregon, and Wisconsin, state withholding
also applies to individuals required to file a state tax return in that state.
Financial organizations are required to offer state withholding for states in which they have a presence. Financial organizations that conduct business
in a state in which they do not have a physical presence should review the withholding regulations in those states to determine if they are also
required to comply with those states’ withholding requirements.
If a state withholding election is not made and state withholding is required, state tax will be withheld.
A state withholding election may be changed at any time and will apply to payments made after the change.
STATE-SPECIFIC RULES
ARKANSAS. IRA distributions are subject to state withholding at 3.0% of the gross payment, unless the IRA owner elects no state withholding.
CALIFORNIA. IRA distributions are subject to state withholding at 1.0% of the gross payment, unless the IRA owner elects no state withholding.
CONNECTICUT. Taxable lump-sum IRA distributions are subject to mandatory state withholding at 6.99% of the gross payment. Any other taxable
distribution from an IRA is subject to state withholding at 6.99% of the gross payment, unless the IRA owner furnishes the financial organization with
a completed Form CT-W4P. Form CT-W4P may be obtained from the Connecticut Department of Revenue Services.
DISTRICT OF COLUMBIA. Lump-sum IRA distributions are subject to mandatory state withholding at 8.95% of the gross payment, except for any
after-tax amount in a lump-sum distribution or a trustee to trustee transfer between IRAs.
IOWA. IRA distributions are subject to state withholding at 5.0% of the gross payment if federal income taxes are withheld from the payment.
KANSAS. IRA distributions are subject to state withholding at 5.0% of the gross payment if federal income taxes are withheld from the payment or if
the IRA owner requests state withholding in writing.
LOUISIANA. IRA distributions are subject to state withholding only when the IRA owner elects state withholding and specifies a percentage not to
exceed 4.8% of the gross payment.
MAINE. IRA distributions are subject to state withholding at 5.0% of the gross payment if federal income taxes are withheld from that payment.
MASSACHUSETTS. IRA distributions are subject to state withholding at 5.0% of the gross payment if federal income taxes are withheld from the
payment. (Exception: A payment is not subject to state withholding if it is excluded from taxation under Massachusetts law.)
MICHIGAN. Any taxable distribution from an IRA received by an IRA owner or beneficiary born after December 31, 1945, is subject to state
withholding at 4.25% of the gross payment, unless the IRA owner furnishes the financial organization with a completed Form MI W-4P. Withholding
also applies to any taxable distributions received by an IRA owner or beneficiary born before 1946 that exceeds certain income thresholds.
Withholding is not required on qualified distributions from Roth IRAs. Form MI W-4P may be obtained from the Michigan Department of Treasury.
MISSOURI. IRA distributions are subject to state withholding at 5.4% of the gross payment, unless the IRA owner elects no state withholding.
MONTANA. IRA distributions are subject to state withholding when an IRA owner elects state withholding and specifies an amount. If state
withholding is elected, the financial organization is not required to withhold the amount specified if it would result in a net payment of less than $10.
NEBRASKA. IRA distributions are subject to state withholding at 5.0% of the gross payment if federal income taxes are withheld from the payment or
if the IRA owner requests state withholding in writing.
NEW JERSEY. IRA distributions are subject to state withholding when an IRA owner elects state withholding and specifies an amount. The IRA owner
must specify an even dollar amount. If state withholding is elected, the financial organization is not required to withhold the amount specified if the
withheld amount would be less than $10 (per payment).
NORTH CAROLINA. IRA distributions are subject to state withholding at 4.0% of the gross payment, unless the IRA owner furnishes the financial
organization with a completed Form NC-4P. Form NC-4P may be obtained from the North Carolina Department of Revenue.
OKLAHOMA. IRA distributions are subject to state withholding at 5.0% of the gross payment if federal income taxes are withheld from the payment
or if the IRA owner requests state withholding in writing.
OREGON. IRA distributions are subject to state withholding at 8.0% of the gross payment, unless the IRA owner elects no state withholding.
VERMONT. IRA distributions are subject to state withholding at 3.0% of the gross payment if federal income taxes are withheld from the payment or
if the IRA owner requests state withholding in writing.
WISCONSIN. IRA distributions are subject to state withholding when an IRA owner elects state withholding and specifies an amount. If state withholding
is elected, the financial organization is not required to withhold the amount specified if the withheld amount would be less than $5 (per payment).
OTHER. This section is reserved for use if a state modifies its withholding requirements.
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