Dd Form 2868 - Request For Withholding State Tax
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1
2DEPARTMENT OF DEFENSE
DEFENSE FINANCE AND ACCOUNTING SERVICE
U.S. MILITARY RETIRED PAY
8899 E. 56TH STREET
INDIANAPOLIS, IN 46249-1300
OFFICIAL BUSINESS
REQUEST FOR WITHHOLDING STATE TAX
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301, Departmental Regulations; 10 U.S.C., Chapters 53, 61, 63, 65, 67, 69, 71, 73, 74; 10 U.S.C. Sec.
1059, and 1408(h); 38 U.S.C. Sec. 1311 and 1313; Pub. L. 92-425; Pub. L. 102-484 Sec. 653; Pub. L. 103-160 Sec. 554 and
1058; Pub. L. 105-261, Sec. 570; DoDI 1342.24, Transitional Compensation for Abused Dependents; DoD Financial
Management Regulation 7000.14-R, Volume 7B and E.O. 9397 (SSN).
PRINCIPAL PURPOSE(S): To appropriately withhold the State income tax from the member's military retired pay as requested
by the member. Applicable SORNs: T7347b.
ROUTINE USE(S): Certain "Blanket Routine Uses" for all DoD maintained systems of records have been established that are
applicable to every record system maintained within the Department of Defense, unless specifically stated otherwise within the
particular record system notice. These additional routine uses of the records are published only once in each DoD
Component's Preamble in the interest of simplicity, economy and to avoid redundancy.
DISCLOSURE: Voluntary; however, if the information is not provided, there may be a significant delay in the processing of the
request to withhold the State income taxes. The Social Security Number is required to correctly identify the retiree in order to
send the correct payroll tax withholding information to the appropriate state taxing authority as directed by the retiree.
1. NAME
2. SOCIAL SECURITY NUMBER
(Last, First, Middle Initial)
3. CURRENT RESIDENCE ADDRESS
(Number and Street, City, State and ZIP Code)
4. AMOUNT FOR WITHHOLDING TAX
5. DESIGNATED STATE
(Must be $10.00 or more in
$
whole dollars)
I hereby request that the above designated amount be withheld from my retired pay account
for State withholding tax purposes for the state indicated.
6. RETIREE'S SIGNATURE
7. DATE
DD FORM 2868, APR 2017
PREVIOUS EDITION IS OBSOLETE.
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