Form Va-4p - Virginia Withholding Exemption Certificate For Recipients Of Pension And Annuity Payments

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FORM VA-4P INSTRUCTIONS
VIRGINIA DEPARTMENT OF TAXATION
WITHHOLDING EXEMPTION CERTIFICATE FOR RECIPIENTS OF
PENSION AND ANNUITY PAYMENTS
you have made a similar election for
your local commissioner of the revenue.
Use this form to notify your pension
federal purposes, or it you meet any of
administrator or other payer whether
the conditions listed in the instructions for
How do I complete Form VA-4P? Review
income tax is to be withheld, and on what
Line 4 of Form VA-4P on the reverse side
the instructions on the reverse side of this
basis.
of this sheet.
page to determine whether you must
file Form VA-4P? Yes.
have income tax withheld. If you are not
Am I required to
What if I have other income? If you have
liable, simply check the box on Line 4 of
You MUST file Form VA-4P with your
pension or annuity payer before your
income from other sources which is not
Form VA-4P. If you are liable, complete
payments begin. If you do not file Form
Virginia income tax withholding,
the Personal Exemption Worksheet below
subject to
VA-4P, your payer is required to withhold
you should consider making estimated tax
and enter your total exemptions
on Line 1
Virginia income tax from your payments
payments on form 760-ES, or requesting
of Form VA-4P. BE SURE TO READ
as if you had claimed zero exemptions.
THE INSTRUCTIONS CAREFULLY
that an additional amount of tax be
BEFORE COMPLETING FORM VA-4P.
withheld from your pension or annuity
may order Form 760-ES
Can I elect "no withholding"'? You may
payment. You
may contact
If you need assistance, you
by calling (804) 440-2541 or contacting
the Department of Taxation at
use this form to elect "no withholding" if
(804) 367-8037.
PERSONAL EXEMPTION WORKSHEET
one else can claim you as a dependent, enter "I " for yourself
1. If no
is not claimed on his/her own certificate, enter "1"
2. If you
are married and your spouse
3. Exemptions for age
a) It you will be 65 or older on December 31, enter "I "
above and your spouse will be 65 or older on December 31,
b) If you claimed an exemption on line 2
enter "I"
4 Exemptions for blindness
a) It you are legally blind enter "I "
b) If you claimed an exemption on line 2 above and your spouse is legally blind,
enter "I"
of dependents you will claim on your income tax return (do not include your spouse)
5. Enter the number
6. Total exemptions (add lines 1 through 5)
CUT HERE AND SEND TO THE PAYER OF YOUR PENSION OR ANNUITY
FORM VA-4P Virginia Withholding Exemption Certificate for
Recipients of Pension and Annuity Payments
SSN
Name
STREET ADDRESS
ZIP CODE
CITY
STATE
Complete the applicable lines below:
1. If Subject to withholding, enter the number of exemptions claimed on line 6 of the Personal Exemption Worksheet
2. Enter the amount of additional withholding requested (see instructions)
3 Enter the amount of voluntary withholding requested (see instructions)
4 1 certify that I am not subject to Virginia withholding, either because I have elected "no withholding' for federal
purposes, or I meet the conditions for exemption set forth in the instructions for Form VA-4P (Check here )
Signature
Date
2601062 Rev 10/03

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