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