Tax Withholding Election Form

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P.O. Box 942716 Sacramento, CA 94229-2716
888 CalPERS (or 888-225-7377)
Tax Withholding Election
California Public Employees’ Retirement System
Section 1: Payee Information
Name (First Name, Middle Initial, Last Name)
CalPERS ID/SSN (Required)
Address
Phone Number
City
State
Zip Code
Please Specify Which Account(s) You Would Like This Election Applied To:
Retirement – Your Own Account
Death Benefit – Option Portion
Survivor Continuance Benefit
Community Property Benefit
Other____________________
Section 2: Federal Tax Withholding Election
Complete the following applicable lines:
1) Check here if you do not want any federal income tax withheld from your pension or annuity. (Do not complete line 2 or 3.) ▶
2) Marital status and total number of allowances you are claiming for withholding from each pension or annuity payment.
(You may also designate an additional dollar amount on line 3.)
Marital status:
Single
Married
Married, but withhold at higher Single rate…… __________________________
(Must enter no. of allowances)
3) Additional amount, if any, you want withheld from each pension or annuity payment………………… $ _________________________
(Note: You cannot enter an amount here without entering the number, including zero, of allowances on line 2.)
Section 3: State Tax Withholding Election
Complete the following applicable lines:
1) Check here if you do not want any State income tax withheld from your pension or annuity. (Do not complete line 2, 3,or 4) ▶
2) Marital status and total number of allowances you are claiming for withholding from each pension or annuity payment.
(You also may designate an additional dollar amount on line 3.)
Marital status:
Single
Married
Head of Household…………………………………………….__________________________
(Must enter no. of allowances)
3) Additional amount, if any, you want withheld from each pension or annuity payment…………..
$ __________________________
(Note: You cannot enter an amount here without entering the number, including zero, of allowances on line 2.)
4) I want this designated amount withheld from each pension or annuity payment…………………….
$ __________________________
(Do not complete lines 1, 2 or 3)
Section 4: Signature and Date
Signature:
Date:
My|CalPERS 1289 (10/16)

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