State And Federal Tax Deduction Form - 2014
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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 take into consideration other income not subject to withholding, including social security income.
Check One:
Married
Married, but withhold at a higher single rate
Single/Widowed
You must make a selection for both the Federal & NM State sections below. Incomplete forms will be returned.
FEDERAL Tax Deductions
NM STATE Tax Deductions
1.
I do not wish to have federal tax deducted from
1.
I do not wish to have State of New Mexico tax
my benefit.
deducted from my benefit.
2.
I wish to claim (#) ______ allowances and have
2.
I wish to claim (#) ______ allowances and have
NMERB determine the amount, if any to be
NMERB determine the amount, if any to be
withheld in accordance with the tax tables.
withheld in accordance with the tax tables.
3.
In addition to #2 above, please withhold an
3.
In addition to #2 above, please withhold an
additional amount of $___________ per month.
additional amount of $___________ per month.
4.
Instead of withholding based on exemptions, I want
4.
Instead of withholding based on exemptions, I want
the following amount withheld from each payment:
the following amount withheld from each payment:
Federal $________________________________
NM State $________________________________
5. No change.
5. No change.
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 _________________________
NMERB USE ONLY
Revised 08/2014
Effective Date: _____________________
By: _______________________________
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