State And Federal Tax Deduction Form
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1701 Camino de los Marquez
Santa Fe, NM 87505
(505) 827-8030 (505) 827-1855
(505) 989-1338
fax
payroll fax
6201 Uptown Blvd. NE Ste. 204
Albuquerque, NM 87110
(505) 888-1560 (505) 830-2976
fax
State and Federal Tax Deduction Form
Please send this completed form to the Santa Fe Office or fax it to the payroll fax number above.
ERB must receive this completed form by the 10th of the month in order to become effective the
same month. Forms received after the 10th of the month will become effective the following month.
Please Print
Full Name ______________________________ Social Security Number ______________________________
I receive a benefit as a beneficiary
Deceased member’s SSN: ________________________________
Mailing Address ___________________________________________________________________________
________________________________________________________________________________________
City
State
Zip
Contact Phone Number: _____________________________________________________________________
Please note that if you do not have taxes withheld from your benefit, you may have to pay estimated
taxes. You may incur penalties if your withholdings or estimated tax payments are not sufficient.
Check the appropriate box(es) below:
FEDERAL Withholding Election:
NEW MEXICO STATE Withholding Election:
1. No withholding—DO NOT withhold federal income tax.
1. No withholding—DO NOT withhold state income tax.
2. Tax table—Withhold federal income tax from each
2. Tax table—Withhold state income tax from each
benefit payment according to my filing status and
benefit payment according to my filing status and
number of exemptions as I have indicated below:
number of exemptions as I have indicated below:
Filing status:
Married
Filing status:
Married
Married at single rate
Married at single rate
Single
Single
Number of exemptions: _________
Number of exemptions: _________
3. Tax table plus extra amount—Withhold federal income
3. Tax table plus extra amount—Withhold state income
tax from each benefit payment according to my filing
tax from each benefit payment according to my filing
status and the number of exceptions, plus the amount I
status and the number of exceptions, plus the amount I
have entered here: $___________________________
have entered here: $___________________________
4. Flat dollar amount—Withhold $__________________
4. Flat dollar amount—Withhold $__________________
in federal tax from each benefit payment.
in state tax from each benefit payment.
5. No change to my existing federal withholding.
5. No change to my existing state withholding.
I understand that this form supersedes any and all previous tax deduction forms. I have completed all
applicable fields in the Federal and NM State Tax Deductions sections of this form. I understand that if
insufficient taxes are withheld, I may be subject to a penalty by the Internal Revenue Service and the State
of New Mexico. I hereby submit this request regarding the treatment of my retirement benefit for purposes
of withholding Federal and State Taxes.
Signed _______________________________________________
Date _________________________
Revised 01/2015
NMERB USE ONLY
Effective Date: ________________ By: ______________________
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