Withholding Election Form printable pdf download

TRUST FUND ADMINISTRATION OFFICE

PENSION DEPARTMENT

FAX: 510-337-3070

WITHHOLDING ELECTION FORM

Instructions: Before completing this form, please read the Notice Regarding Federal and State Tax Withholding on the

reverse side of this form.

Step 1

Personal Information

Type or Print Your Full Name

Your Social Security Number

—

Home Address (number and street or rural route)

Phone Number

(

)

—

City

State

Zip Code

Step 2

Federal Tax Withholding

Please check only one box:



I do not want federal income tax withheld from my monthly pension.



I do want federal income tax withheld from my monthly pension.

If you state you do want federal income tax withheld from your monthly pension, please complete

the section below to specify which type of withholding you are requesting.

If you have checked the box to withhold taxes above, you can have tax withheld in two ways:



According to your withholding status (Single or Married) and the number of exemptions you

elect. The amount withheld will be determined by the tables the IRS publishes and you may

change your election each year; or



According to the method mentioned above in addition to the dollar amount you specify

(whole dollars only).



Number of Exemptions

Please complete

Single

Claimed ____________

Please withhold as:

either A



Married

or A and B

ADDITIONAL

dollar amount to Item A,

(Selecting B alone is

if any (flat dollar amounts are NOT

not a valid election.)

$ _______.00

allowed)

Step 3

State Tax Withholding

I am a resident of _________________________.

Your state

Please check only one box:



I do not want state income tax withheld from my monthly pension.



I do want state income tax withheld from my monthly pension.

If you do want state income tax withheld from your monthly pension, please complete the section

below to specify which type of withholding you are requesting.

If you have checked the box to withhold taxes above, you can have tax withheld in two ways:



The dollar amount you specify (whole dollars only).



In an amount equal to 10% of the amount of federal taxes being withheld.

Dollar amount to be withheld from each

Please complete

monthly payment (flat amount):

either A or B

$ _______.00

(Select only one.)

Please withhold in an amount equal to

Check here to

10% of the amount of Federal withholding.

select option B

______

Step 4

Signature Required

Sign Here:

Date:

2012 Withholding Notice

Withholding Election Form

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