Tax Withholding Election - State Of Delaware - Office Of Pensions
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1
2State of Delaware
New Address
Office of Pensions
McArdle Building
860 Silver Lake Blvd., Suite 1,
Dover, DE 19904-2402
PRINT FORM
CLEAR FORM
Pension Plan Income Tax Withholding Election Form In Lieu of W4P
_______________________________________
________________________________
Name
EmplID
__________________________________
____________________________
Social Security Number
Telephone Number
__________________________________
____________________________
Street Address
City, State, Zip+4
Sign and date the bottom of the form. Your request cannot be processed if the form is not signed.
Return it by mail to the address above or by fax to (302) 739-6129.
If you have questions about this form or how to fill it out, call (302) 739-4208 or (800) 722-7300.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
.
I elect NO Federal income tax to be withheld from my monthly pension
1
I elect NO State income tax to be withheld from my monthly pension.
2.
I elect to have my monthly withholdings calculated using the tax tables based on the
following marital status and number of allowances:
Federal withholdings:
________
Single ~ # of allowances ________
Married ~ # of allowances
________
Married but withhold at the higher single rate ~ # of allowances
Also, withhold $___________ in addition to this calculation.
State withholdings:
________
Single ~ # of allowances ________
Married ~ # of allowances
________
Married but withhold at the higher single rate ~ # of allowances
Also withhold $__________ in addition to this calculation.
3.
I elect to have ONLY the following flat dollar amount withheld from my
monthly pension:
Federal tax withholdings $_____________
State tax withholdings $_____________
4.
I elect to have the following dollar amount withheld IN ADDITION to my current
monthly withholdings.
Federal tax withholdings $_____________
State tax withholdings $__________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I understand that the withholding elections requested above will remain in effect until I change them. I
understand that I may revoke or change my tax withholding election at any time by notifying the Office
of Pensions in writing.
_______________________________________________
________________
Signature of Pensioner or Legal Guardian
Date
Turn this page over for instructions on filling out this form.
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