Form Mo W-4p Draft - Withholding Certificate For Pension Or Annuity Statements - 2010

FORM

This certificate is for voluntary with-

MISSOURI DEPARTMENT OF REVENUE

MO W-4P

holding of Missouri State Income Tax

WITHHOLDING CERTIFICATE FOR

from pension or annuity income only.

PENSION OR ANNUITY STATEMENTS

(REV. 09-2010)

FULL NAME (TYPED OR PRINTED)

SOCIAL SECURITY NUMBER

–

HOME ADDRESS (NUMBER AND STREET OR RURAL ROUTE)

CLAIM OR IDENTIFICATION NUMBER (IF

ANY) OR YOUR PENSION OR ANNUITY

CONTRACT.

CITY OR TOWN, STATE, ZIP CODE

COMPLETE THE FOLLOWING APPLICABLE LINES

1. I elect NOT to have income tax withheld from my pension or annuity. (If you check this box, do not complete Line 2.)

2. I voluntarily elect to have the following amount withheld from each pension or annuity payment each month. (The amount you

enter cannot be less than $10.00 per month.) For assistance in determining an amount to be

withheld, visit our web site at:

YOUR SIGNATURE

DATE

__ __ / __ __ / __ __ __ __

MO 860-1961 (09-2010)

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Parent category: Financial