Form Mo W-4p - Withholding Certificate For Pension Or Annuity Statements
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This certificate is for voluntary
MISSOURI DEPARTMENT OF REVENUE
FORM
withholding of Missouri State Income
MO W‑4P
WITHHOLDING CERTIFICATE FOR
Tax from pension or annuity income
PENSION OR ANNUITY STATEMENTS
(REV. 01‑2012)
only.
This form is to be provided to the administrator of your retirement plan ‑
DO NOT SEND TO THE DEPARTMENT OF REVENUE.
FULL NAME (TYPED OR PRINTED)
SOCIAL SECURITY NUMBER
–
–
STREET ADDRESS
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:
$
DATE
YOUR SIGNATURE
INSTRUCTIONS FOR COMPLETING FORM MO‑W4P
1. Enter your full name, address and social security number.
2. Enter your pension or annuity contract claim or identification number.
3. If you DO NOT wish to have Missouri state income taxes withheld from your pension or
annuity income, place a check mark in the box next to Line 1. Sign and date the form.
Then send this form to the administrator of your retirement plan who will simply keep your
completed form on file.
4. If you DO wish to have Missouri state taxes withheld from your pension or annuity income,
place a check mark in the box next to Line 2. Then enter the amount you wish to have
withheld MONTHLY in the box provided. To determine the amount to be withheld monthly,
divide the amount of tax you paid with last year’s Missouri income tax return by twelve. You
may wish to allow for the effect of any increases in your income from last year’s income by
adjusting your calculation of the amount to be withheld upwards. The amount to be withheld
cannot be less than $10.00. Sign and date this form. Then send this form to the administrator
of your retirement plan who will then begin the withholding.
5. Should you need to change this form or complete a new one, please contact the administrator
of your retirement plan.
TDD 1‑800‑735‑2966
MO W‑4P (01‑2012)
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