Form Va-4p - Virginia Withholding Exemption Certificate For Recipients Of Pension And Annuity Payments

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FORM VA-4P INSTRUCTIONS
VIRGINIA DEPARTMENT OF TAXATION
WITHHOLDING EXEMPTION CERTIFICATE FOR RECIPIENTS OF
PENSION AND ANNUITY PAYMENTS
Use this form to notify your pension
made a similar election for federal purposes,
You may also order
administrator or other payer whether
or if you meet any of the conditions listed in
Form 760-ES by calling (804) 367-8037 or
income tax is to be withheld, and on what
the instructions for Line 4 of Form VA-4P on
contacting your local commissioner of the
basis.
the reverse side of this sheet.
revenue.
Am I required to file Form VA-4P? Yes. You
What if I have other income? If you have
How do I complete Form VA-4P?
MUST file Form VA-4P with your pension or
income from other sources which is not
Be sure to read the instructions on the
annuity payer before your payments begin.
subject to Virginia income tax withholding,
reverse side of this page carefully before
If you do not file Form VA-4P, your payer
you should consider making estimated tax
completing Form VA-4P. If you need
is required to withhold Virginia income tax
payments on form 760-ES, or requesting
assistance, you may contact the Department
from your payments as if you had claimed
that an additional amount of tax be withheld
of Taxation at (804) 367-8037.
zero exemptions.
from your pension or annuity payment. You
can download Form 760-ES or electronically
Can I elect “no withholding”?. You may use
file your estimated payment on our website,
this form to elect “no withholding” if you have
PERSONAL EXEMPTION WORKSHEET
1.
Enter “1” for yourself...................................................................................................
2.
If you are married and your spouse is not claimed on his or her own certificate,
enter “1” ......................................................................................................................
3.
Enter the number of dependents you will claim on your income tax return
(do not include your spouse) ......................................................................................
4.
Subtotal of Personal Exemptions - add lines 1 - 3 ......................................................................................
___________________
5.
Exemptions for age
a)
It you will be 65 or older on January 1, enter “1” .................................................
b)
If you claimed an exemption on line 2 above and your spouse will
be 65 or older on January 1, enter “1”.................................................................
6.
Exemptions for blindness
a)
If you are legally blind enter “1” ...........................................................................
b)
It you claimed an exemption on line 2 above and your spouse is
legally blind, enter “1 “ .........................................................................................
7.
Subtotal of Age and Blindness Exemptions - add lines 5 & 6 .....................................................................
___________________
8.
Total exemptions (add lines 4 and 7) ......................................................................................................
___________________
--------------------------------------- CUT HERE AND SEND TO THE PAYER OF YOUR PENSION OR ANNUITY -------------------------------------
FORM VA-4P Virginia Withholding Exemption Certificate for
Recipients of Pension and Annuity Payments
Your Social Security Number
Name
Street Address
City
State
Zip Code
Complete the applicable lines below:
1.
If subject to withholding, enter the number of exemptions claimed on
(a) Subtotal of Personal Exemptions - line 4 of the Personal Exemption Worksheet ..................................
___________________
(b) Subtotal of Age and Blindness Exemptions - line 7 of the Personal Exemption Worksheet ..................
___________________
(c) Total Exemptions - line 8 of the Personal Exemption Worksheet ...........................................................
___________________
2.
Enter the amount of additional withholding requested (see instructions) ....................................................
___________________
3.
Enter the amount of voluntary withholding requested (see instructions) .....................................................
___________________
4.
I certify that I am not subject to Virginia withholding, either because I have elected “no withholding”
for federal purposes, or I meet the conditions for exemption set forth in the instructions for
j
Form VA-4P. ........................................................................................................................ (Check here.)
Signature _______________________________________________________________________
Date _______________________________

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