Substitute State Tax Withholding Certificate Form: Iowa

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Pension Fund of the Christian Church
Substitute State Tax Withholding Certificate: Iowa
I: INSTRUCTIONS
You are required to make a state withholding election for your account(s) held by Pension Fund of the Christian
Church by completing this Substitute State Withholding Certificate. If withholding is required by your state and
you do not make an election, or if your election is less than the amount required, Pension Fund will apply
withholding at the minimum rate based on your state of residency. If you elect not to have state income tax
withheld, and you reside in a state that requires that state income taxes be withheld for certain types of
payments, Pension Fund will comply with state law.
Your election on this Certificate will remain in effect for all distributions from your account(s) to which it
applies until you revoke it. You may revoke and/or change your election at any time by completing a new
Substitute State Withholding Certificate and returning it to Pension Fund. Any new election will be effective as
soon as practicable after receipt. You may revoke an election and/or make a new election as often as you wish.
IMPORTANT NOTE: While this Certificate is intended to provide you with information regarding
your state income tax withholding law, Pension Fund cannot guarantee the accuracy or timeliness of
information because state tax laws are subject to change and interpretation. We recommend that you
consult with your legal or tax advisor, or with your state department of revenue, for the most up-to-date
information for your state of tax residence. Certificate must be completed in its entirety to be valid.
II: MEMBER INFORMATION
Full Name (Type or Print)
Social Security Number
__ __ __ - __ __ - __ __ __ __
Address (Street/P.O. Box/Rural Route)
City/State/ZIP Code
Phone Number
III: TAX ELECTION INFORMATION
State withholding is required if you elect to have Federal tax withheld. If you elect not to have Federal tax
withheld, you may still elect state withholding.
1
Option 1. I do not want state income tax withheld from my plan distribution(s).
STOP here.
Option 2. I want to have state income tax calculated and withheld from my plan distribution(s)
based on my substitute W-4P on file at Pension Fund. If you wish to change your tax elections
for federal and state tax elections, please contact Pension Fund for an additional W4-P.
Claiming no exemptions _____________________.
2
I want the following additional amount withheld from my plan distribution: $_________.
1
Please see back page.
2
Please see back page.
V1 11-2015

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