Tiaa Mandatory State Income Tax Withholding Election For Periodic Withdrawals That Are Not Rollover Eligible Page 4
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4MANDATORY STATE INCOME TAX WITHHOLDING ELECTION
FOR PERIODIC WITHDRAWALS THAT ARE NOT ROLLOVER ELIGIBLE
Page 2 of 2
3. WITHHOLDING ELECTION
Based on your state of legal
residence, state income
Arkansas
Married with 3
Massachusetts
0 exemptions
taxes will be withheld
allowances
Michigan
4.25%
from your payments at the
California
10% of federal
following rate, unless you
Nebraska
Married with
withholding
choose one of the available
3 allowances
options.
Delaware
5%
North Carolina
Single with
District of Columbia
No Withholding
0 allowances
PLEASE NOTE: Marital status
Georgia
Married with 3
Oklahoma
Married with
and allowances are only
allowances
3 allowances
an option for residents of
Iowa*
5%
Oregon
Single with
Arkansas, Georgia, Maine,
0 exemptions
Michigan, Nebraska, North
Kansas
No Withholding
Carolina, Oklahoma, Oregon
Vermont
Married with
Maine
Single with
and Vermont.
3 allowances
0 exemptions
Virginia
0 exemptions
Maryland
No Withholding
* Iowa residents: If you do
not make a state election
If you would like state withholding from your distribution in an amount OTHER THAN the state prescribed rate, please
and your payments are
check the appropriate box below and indicate your election.
less than $500 per month,
there will be no state
Marital Status:
withholding.
Single
Married (Does not apply to Massachusetts and Virginia)
Married Filing Separate (Applies Only to Geogia)
Head of Household (Applies Only to Arkansas, Georgia, Massachusetts and North Carolina)
Total number of withholding allowances
Withhold the following ADDITIONAL amount from each payment $
I choose the following percentage be withheld from the taxable portion of my payment
%
I choose NOT to have taxes withheld from my payment or my distribution is exempt. (For Iowa, Maine, Massachusetts
and Nebraska Only: You can elect no state withholding only if you have elected no federal withholding.)
4. YOUR SIGNATURE
This form will become effective with your next available payment. You may revoke this election at any time by filing a new
state income tax withholding election form with TIAA.
Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification
number (or I am waiting for a number to be issued to me); and (2) I am not subject to backup withholding because:
(a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I
am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified
me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen or other U.S. person; and (4) The
FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Note: Item 4 serves no purpose beyond required reproduction of the official Form W-9 language. Please disregard item 4.
Please sign your full legal
The Internal Revenue Service does not require your consent to any provision of this document other than the
name with suffix, if
certifications required to avoid backup withholding.
applicable, using black
or dark blue ink. Digital
Your Signature
Today’s Date
(mm/dd/yyyy)
signatures are not
2 0
/
/
accepted.
F11434 (6/16)
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