Form Wh-4p - Annuitant'S Request For State And County Income Tax Withholding - Indiana

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Form WH-4P

State of Indiana

Annuitant’s Request

State Form 37365

(R2 / 8-08)

for State and County Income Tax Withholding

(Please Type or Print Clearly)

Full Name _________________________________________________________________________

Social Security Number

Home Address (number and street) _____________________________________________________

City, State, and Zip code ______________________________________________________________

Annuity contract claim or identification number ................................................................................................... A.

_______________

Enter the amount of Indiana state tax to be withheld from each annuity or pension payment ............................ B. $ _______________

Enter your 2-digit county code

and the amount of county tax to be withheld from each annuity or

pension payment ................................................................................................................................................. C. $ _______________

Total amount withheld: add line B plus line C (must be $10 or more) ................................................................. D. $ _______________

I request voluntary income tax withholding from my annuity or pension payments.

_________________________________________________________

____________________________

Signature of Annuitant

Date