Fillable Tax - NPERS3605 Withholding Certificate

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Tax - NPERS3605 Withholding Certificate

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Country of origin: US
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NPERS3605
Rev. 03/2017
Page 1 of 1
BAR CODE
Name
LAST FIRST MIDDLE
Date of Birth
PLAN TYPE
(Check One)
Social Security Number
Email
SCHOOL
STATE
COUNTY
JUDGES
PATROL
DCP
Home Phone
Work Phone
Employer
SECTION 1
NEBRASKA RESIDENTS (Fill out ONLY this section.)
Nebraska residents, please check the box to select ONE of the following options (A, B, or C):
OPTION A: I WANT federal and state income tax withheld from my periodic annuity payments,
based on the number of exemptions and the marital status I claim below.
Total number of exemptions/withholdings claimed: ________
MARITAL STATUS: Single Married Married, but withholding at a higher single rate
(Select ONLY ONE of the above. Note that “Widow” or “Widower” is not a status.)
IF YOU SELECTED OPTION A: (Optional)
Note any ADDITIONAL (not total) monthly federal withholding: $____________
Note any ADDITIONAL (not total) monthly state withholding: $____________
OPTION B: I do NOT want federal OR state income tax withheld.
OPTION C: I do NOT want federal income tax withheld BUT please withhold a flat monthly amount
of $____________ for state income tax.
SECTION 2
NON-RESIDENTS
OF
NEBRASKA (Fill out ONLY this section.)
Complete this section only if you do NOT reside in Nebraska. Please check the box to select ONE of the
following options (A or B):
OPTION A: I WANT federal income tax withheld from my periodic annuity payments, based on the
number of exemptions and the marital status I claim below.
Total number of exemptions/withholdings claimed: ________
MARITAL STATUS: Single Married Married, but withholding at a higher single rate
(Select ONLY ONE of the above. Note that “Widow” or “Widower” is not a status.)
IF YOU SELECTED OPTION A: (Optional)
Note any ADDITIONAL (not total) monthly federal withholding: $____________
OPTION B: I do NOT want federal income tax withheld.
Questions regarding your individual tax liability should be directed to your accountant, the Internal Revenue Service and/or the Nebraska
Department of Revenue. The Public Employees Retirement Systems staff are not qualified to answer your personal tax questions.
X
Member’s
Signature
DATE
Withholding Certificate for Annuity Payments
If you are a new
retiree or benefit recipient and you do not complete and return this form, we are required to withhold federal
and Nebraska state income taxes as if you are a married
individual claiming three exemptions.
IMPORTANT
I realize I am liable for payment of federal income tax on the taxable portion of my annuity and that I may be subject to tax penalties
under the estimated tax payment rules if my payment(s) of estimated tax and withholding are not adequate.
I hereby submit this Withholding Certificate regarding how my benefit is to be treated for purposes of federal and Nebraska state
income tax withholding.
Must be a dollar amount.
No percentages
or fractions.
Must be a dollar amount.
No percentages or fractions.
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Completed 7 April 2020

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