Pera Tax Deduction Form Fillable 2015
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233 Plaza La Prensa, Santa Fe, New Mexico 87507
(505) 476-9401 fax
(505) 476-9300 voice
(800) 342-3422 Toll-Free
PERA TAX DEDUCTION FORM
Instructions: Please print or type in dark ink. The original of this form must be completed in its entirety and returned to PERA
BOLD ITALICS
for processing. Required Fields are in
. Additional instructions are on the back page.
Check One:
New
Change In Existing Information
SOCIAL SECURITY NUMBER or PERA ID NUMBER
NAME
Middle Initial
Last
First
MAILING ADDRESS
City
State
Zip Code
TELEPHONE or CELLULAR NUMBER
CHECK ONLY THE APPLICABLE BOXES
Do not deduct federal withholding tax from my benefits.
Do not deduct New Mexico state withholding tax from my benefits. (If you are living out-of-state, please check
this box. PERA cannot withhold other States income taxes.)
I realize that I am liable for payment of federal and state income tax on the taxable portion of my pension and that I may
be subject to tax penalties under the estimated tax payment rules if my payments of estimated tax withholdings are not
adequate.
The following exemptions are being claimed, and I want PERA to determine the amount, if any, of federal/New
Mexico state income tax to be withheld in accordance with the tax tables and exemptions claimed below:
Married rate
Single rate
Exemptions claimed:
1 for yourself
1 for your spouse
1 if you are 65 or older
1 if your spouse is 65 or older
1 if you are blind
1 if your spouse is blind
Other
Total exemptions claimed
In addition to the withholding on my exemptions, I want the following additional amount withheld from each
monthly payment
Federal Tax $ __________________ New Mexico State Tax $ ___________________
Instead of withholding based on exemption, I want the following amount withheld from each monthly payment.
Federal Tax $ __________________
New Mexico State Tax $ ___________________
AUTHORIZATION
I submit this PERA Tax Deduction Form specifying what deductions I authorize to be made from my PERA retirement
benefit for federal and New Mexico state income tax purposes.
_________________________________________
_______________
SIGNED
DATE
September 2015
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