W-4p Substitute - Withholding Certificate For Pension Benefit Payments
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1MoDOT & Patrol Employees’ Retirement System
W-4P Substitute
PO Box 1930
Jefferson City, MO 65102-1930
1.
Complete all sections of this form.
Phone: (573) 298-6080
(800) 270-1271
2.
Sign and date the form.
Fax: (573) 522-6111
Email:
3.
Return the form to MPERS prior to the
Website:
th
15
of the month.
Withholding Certificate for Pension Benefit Payments
PERSONAL INFORMATION
Name:
(Last)
(First)
(MI)
Social Security Number:
xxx - xx -
Type of Benefit Payment (check one):
Retirement
Disability
Ex-Spouse
Survivor/Beneficiary
Mailing Address:
Start Date*: Month/Year
City:
State:
Zip Code:
Daytime Phone:
(
)
Signature:
Date:
*Start date is the date you wish tax withholding to begin.
FEDERAL TAX WITHHOLDING (CHECK ONLY ONE FEDERAL OPTION)
No Federal Tax Withholding – I elect not to have income tax withheld from my
Option 1
pension benefit. This option does not relieve me of any tax liability.
Federal Withholding Based on Marital Status and Number of Allowances –
Option 2
I want my withholding from each periodic pension benefit payment to be determined
using the following marital status and allowances:
□
□
□
Marital Status:
Single
Married
Married, but withhold at single rate
Number of Allowances: _____________ (will use zero allowances if incomplete)
Under Option 2, you may elect an additional flat amount to be withheld each month.
In addition to the amount based on the allowances specified above,
I want an extra $______________ withheld from each pension benefit payment.
If you do not submit a federal tax withholding form, or do not choose a federal tax withholding option,
MPERS is required by law to withhold federal taxes as if you elected married with three allowances.
MISSOURI STATE TAX WITHHOLDING (CHECK ONLY ONE OPTION)
No Missouri State Tax Withholding – I elect not to have income tax withheld from
Option 1
my pension benefit. This option does not relieve me of any tax liability.
Flat Amount (Minimum $10) – I want $_____________ withheld from each
Option 2
pension benefit payment. This must be a flat amount (no cents).
4/16
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