Tax Withholding Preference/change Certificate - Minnesota Public Employees Retirement Association
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PUBLIC EMPLOYEES RETIREMENT ASSOCIATION
60 Empire Drive, Suite 200, St. Paul, MN 55103-2088
Telephone: (651) 296-7460; or Toll Free 1 (800) 652-9026
Fax: (651) 297-2547
TAX WITHHOLDING PREFERENCE/CHANGE CERTIFICATE
INSTRUCTIONS: Use this form to instruct PERA as to whether or not you wish federal and/or Minnesota state
taxes withheld, or to change your current tax withholding from your PERA benefit. Print your full name, the last four
digits of your Social Security number, and PERA number (if known). Indicate in Part A whether or not federal taxes
are to be withheld. Indicate in Part B whether or not Minnesota state taxes are to be withheld. This form must be
signed on the reverse side to be valid. Return this completed form to PERA by mail or fax.
IMPORTANT: The information on this form will be used to identify your records and to report federal and/or
Minnesota state income tax withholding as required by law. Except for your name, the data you supply is classified
as PRIVATE; that is, it is available only to you, the staff who must use it in the normal course of conducting PERA
business, the Internal Revenue Service, and the Minnesota Department of Revenue. Failure to disclose the data
requested may result in inaccurate reporting of your income tax. No matter which option you choose, you will be
responsible for any taxes that are due.
Name—Last, First, Middle Initial (Please Print)
Last Four Digits of Your Social Security No.
PERA ID No.
[
Address—Street, City, State, and Zip Code (Please Print)
Check (
) Box if Change of Address
□
Indicate the PERA plan providing this benefit payment (Check () only one ):
Statewide Volunteer Firefighter Plan
□
□
□
□
Coordinated/Basic Plan
Correctional Plan
Police & Fire Plan
Minneapolis Employees Retirement Fund
PART A
FEDERAL INCOME TAX WITHHOLDING :
.
Complete this section to change your federal withholding
You have three options as to how you wish PERA to withhold federal income tax from your benefit, as explained below. Read
each option carefully before making a selection. Use a check mark to indicate your choice (1, 2, or 3). If you do not make a
selection, PERA is required by law to withhold federal tax from your benefit assuming a status of married with three exemptions.
This assumption or your preferred method of withholding will be in effect until you change it.
[
CHECK (
) ONLY ONE BOX
1.
I do not wish to have federal tax withheld from my monthly benefit.
2.
I wish to have federal tax withheld from my monthly benefit based on current tax tables using the marital status and
number of withholding exemptions I claim below. (Tax tables available at )
3. I wish to have $ _______________ in total federal taxes withheld from my monthly benefit. NOTE: To enter an
amount here, you must enter marital status and exemptions below. If this amount is less than the tax table calcula-
tion, based on the marital status and exemptions you selected, withholding will be based on the tax table calculation.
COMPLETE BELOW ONLY IF YOU CHECKED BOX 2 OR 3 ABOVE
Marital Status:
Single
Married
Exemptions (Check all that apply)
Yourself
Spouse
Other (Indicate No.) __________
TOTAL EXEMPTIONS CLAIMED: ____________
PW-00100-01 dao 12/2/2015
Continued on Reverse Side
This form must be signed on the reverse side to be valid.
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