Form Wh-4p - Annuitant'S Request For State And County Income Tax Withholding - Indiana Page 2

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You may select any amount over $10.00 to be withheld from your annuity or pension payment. This withholding will be
reported to you on a W-2P at the end of each year as Indiana State and County Tax Withheld. Beginning January 1, 2009
an annuitant can request the payor of an annuity or pension to withhold a portion of their pension or annuity to offset their
county tax liability under IC 6-3.5.
A.
Enter the Contract, Policy, or Account Number to which the request applies.
B.
Enter an amount of state tax that you wish to have withheld from each check.
C.
Enter your 2-digit county code and the amount of county tax to be withheld from each annuity or pension payment
D.
Total amount withheld: add line B plus line C (must be $10 or more)
Send this form to the person or company paying your pension. Do not send this to the Department of Revenue.

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