Fillable Retiree Tax Withholding Election Form W4-P

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Retiree Tax Withholding Election Form W4-P

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Retiree Tax Withholding Election Form – W4-P
Type or print in ink.
RETIREE INFORMATION
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
NEW ADDRESS?
YES NO
MAILING ADDRESS:
STATE:
ZIP CODE:
HOME ADDRESS:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS:
FEDERAL WITHHOLDING ELECTION
OPTION 1:
I want federal income tax withheld from my monthly retirement benefit as follows:
Marital Status:
Single
Married
Number of withholding allowances (enter “0” of zero):
I want the following amount withheld in addition to the federal tax table:
$
OPTION 2:
I do not want federal income tax withheld from my monthly retirement benefit.
(Not availa
ble to U.S. Citizens living in a foreign country)
CALIFORNIA STATE WITHHOLDING ELECTION
OPTION 1:
I want California State income tax withheld from my monthly retirement benefit as follows:
Marital Status:
Single
Married
Number of withholding allowances (enter “0” of zero):
I want the following amount withheld in addition to the California tax table:
$
OPTION 2:
I do not want California State tax withheld from my monthly retirement benefit.
OPTION 3:
I want the designated flat amount withheld from each monthly retirement benefit.
$
AUTHORIZATION
Any prior Federal or California State withholding form on file with StanCERA is hereby revoked. I further
understand that any request received by StanCERA on or before the 10
th
of the month, will become effective the
next payroll process.
Retiree Signature:
Printed Name:
Date:
STANCERA USE ONLY:
ENTERED BY:
DATE ENTERED:
REVIEWED BY:
DATE REVIEWED:
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Retiree Tax Withholding Election Form W4-P

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Completed 1 January 2021

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