Federal Income Tax Withholding Certificate
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1Public Employees’ Retirement System of Nevada
693 W. Nye Lane, Carson City, NV 89703 (775) 687-4200 Fax (775) 687-5131
5820 S. Eastern Ave., Suite 220, Las Vegas, NV 89119 Fax (702) 678-6934
Toll Free 1-866-473-7768 Website
Federal Income Tax Withholding Certificate
Please print or type in black ink.
Your Name:
______________________________
Social Security Number:_________________________________Phone: (
)________________________
If you receive more than one benefit check each month, please select ALL ACCOUNTS to which these instructions
are to be applied:
□
□
□
Your Retirement Benefit
Beneficiary/Survivor Benefit
Alternate Payee Benefit
******************************************************************************************
Select ONE of the following three options.
Option #1
I do not wish to have federal income tax withheld from my benefit. I realize I am liable for payment of federal
taxes on my retirement benefits and I may be subject to tax penalties under the estimated tax payment rules if my
payments are inadequate.
Option #2
I authorize PERS to calculate the amount of taxes to be withheld based on the following information:
Marital Status: (must mark one)
Single
Married
Exemptions Claimed:
1 for yourself
1 for your spouse
Other exemptions
Total
I also authorized the additional amount of $____________ to be added to the amount calculated based upon the above
instructions.
Option #3
________I authorize PERS to withhold the following flat-rate amount from my monthly check/s $__________________.
I have reviewed the information on this form and hereby submit these instructions for purposes of federal income tax
withholding.
Signature:
Date:
Rev. 4/07
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