Form It-2104-P - Annuitant'S Request For Income Tax Withholding
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1IT-2104-P
Department of Taxation and Finance
Annuitant’s Request for Income Tax Withholding
(8/15)
New York State • New York City • Yonkers
First name and middle initial
Last name
Your social security number
Permanent mailing address
Apartment number
Annuity contract claim or
(number and street or PO box)
identification number
City, village, or post office
State
ZIP code
Enter the whole dollar
1 New York State income tax ..................................................................
1
amount to be withheld
2 New York City income tax
.............................
2
(if a New York City resident)
from each annuity or
3 Yonkers income tax surcharge
..............................
3
(if a Yonkers resident)
pension payment:
I request voluntary income tax withholding from my annuity or pension payments as authorized by section 671(b) of the Tax Law.
Signature of annuitant
Date
IT-2104-P (8/15) (back)
Instructions
Payee
Statement of income tax withheld
After the end of the year, your payer will give you federal Form 1099‑R,
Who may file
Distributions From Pensions, Annuities, Retirement or Profit‑Sharing Plans,
If you receive an annuity or pension payment that must be included in your
IRAs, Insurance Contracts, etc., showing the gross amount of annuity or
New York adjusted gross income, you may file this form to have New York
pension payments and the total amount deducted and withheld as tax during
State income tax (and, if a New York City or Yonkers resident, that city’s
the calendar year.
personal income tax) withheld from each payment. However, the annuity or
pension must be payable over a period longer than one year.
Payer
Keep this certificate with your records.
Where and how to file
File this form with the payer of your annuity or pension. Enter on the front the
See the instructions for Form NYS‑1, Return of Tax Withheld, and
whole dollar amount(s) that you want withheld from each annuity or pension
Form NYS‑45, Quarterly Combined Withholding, Wage Reporting, and
payment. However, each amount must be at least $5 per month and should
Unemployment Insurance Return, for payment and reporting requirements for
not reduce the annuity or pension payment you receive to less than $10.
New York State, New York City, and Yonkers personal income taxes that you
Quarterly payments of estimated income tax may be made in addition to or
withheld from annuity or pension payments.
instead of withholding; see Form IT‑2105‑I, Instructions for Form IT‑2105, for
more information.
Privacy notification
See our Web site or Publication 54, Privacy Notification.
If you need help completing this form, call (518) 457‑5181.
Duration of withholding request
Your request for voluntary withholding will remain in effect until you terminate it.
How to terminate a withholding request
You may terminate your request for voluntary withholding by giving your payer
a written termination notice.
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