Tax Withholding Preference/change Certificate - Minnesota Public Employees Retirement Association Page 2

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PART B
MINNESOTA INCOME TAX WITHHOLDING:
.
Complete this section to change your state withholding
You have four options as to how you wish PERA to withhold Minnesota state 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, 3, or 4). If you do not
make a selection here, PERA will continue to withhold state taxes at your current rate. If you made no previous election, PERA
will not withhold for Minnesota income taxes unless you so indicate below. This assumption, or your preferred method of
withholding, will be in effect until you change it.
[
CHECK (
) ONLY ONE BOX. PLEASE NOTE: PERA can withhold state tax for Minnesota only.
1.
I do not wish to have Minnesota state tax withheld from my monthly benefit.
2.
I wish to have Minnesota state tax withheld from my monthly benefit based on current tax tables and the marital
status and number of withholding exemptions I claim below. (Tax tables available at )
3.
I wish to have a Minnesota state tax fixed amount of $ ___________________ withheld from my monthly benefit.
4.
I wish to have a Minnesota state tax fixed percentage amount of ___________________% withheld from my monthly
benefit.
COMPLETE BELOW ONLY IF YOU CHECKED BOX 2
Marital Status:
Single
Married
Exemptions: (Check all that apply)
Yourself
Spouse
Other (Indicate No.) __________
TOTAL EXEMPTIONS CLAIMED _____________
PART C
SIGNATURE:
Member must complete this section.
IMPORTANT: FORM MUST BE SIGNED TO BE VALID
This form may be completed and signed by a legal representative of the payment recipient (under a Power of Attorney agreement or
court-ordered Conservatorship, for example). Legal representatives should include a copy of any agreement or court order granting the
legal representative the authority to act on behalf of the payment recipient with this form.
I have read and understand the information on this form and request that PERA withhold income taxes from my benefit in the
manner described above. I realize that my withholding method(s) will continue until I change them.
_____________________________________________________________
______________________________
Signature of Recipient
Date
PW-00100-01 dao 12/2/2015
Print Form

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