WEST VIRGINIA EMPLOYEE WITHHOLDING EXEMPTION CERTIFICATE
INSTRUCTIONS
Complete this form and present it to the West Virginia Consolidated Public Retirement Board to avoid delay
in adjusting the amount of state income tax withholding for your retirement benefits.
If you do not complete this form, the amount of tax that is now being withheld from your retirement benefits
may not be sufficient to cover the total amount of tax due when filing your personal income tax return after the
close of the year.
When requesting withholding from your pension and annuity payments you must present this completed form
to the West Virginia Consolidated Public Retirement Board on or before the tenth calendar day of the month
in order to ensure that the withholding change will occur during that month. (If you are applying for
retirement, please return with your retirement application.)
Tax penalties may result if a large amount of tax is owed at the end of the year.
When requesting West Virginia State Withholding, please follow the instructions listed below:
1. If you want us to calculate the amount withheld, please enter the number of exemptions on line “4”.
2. If you want an additional dollar amount, please indicate the additional amount to be withheld on line
“5”.
3. If you want a specific fixed dollar amount deducted each month, please enter the dollar amount on line
“6”.
4. If you do not want to have West Virginia State Tax withheld, please check 9line “7”.
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EMPLOYEE'S WITHHOLDING EXEMPTION CERTIFICATE
(1) ______________________________________________________ (2) _________________________
Print or Type Full Name Social Security Number
(3) __________________________________________________________________________________
Home Address City or Town State Zip
(4) Total number of exemptions claimed ....................................................................... _________, and
(5) ADDITIONAL dollar amount, if any, you want deducted each pay period ............ $_________, or
(6) TOTAL fixed dollar amount, if any, you want deducted each pay period ................ $_________, or
(7) I do not wish to have WV State Tax withheld (check 9 here) ………………………..
I CERTIFY, under penalties provided by law, that the number of exemptions claimed in this certificate is
not in excess of those to which I am entitled.
Date:____________________ Signature:__________________________________________________
