Dd Form 2868 - Request For Withholding State Tax - Department Of Defense

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DEPARTMENT OF DEFENSE
DEFENSE FINANCE AND ACCOUNTING SERVICE
U.S. MILITARY RETIREMENT PAY
P.O. BOX 7130
LONDON, KY 40742-7130
OFFICIAL BUSINESS
REQUEST FOR WITHHOLDING STATE TAX
PRIVACY ACT STATEMENT
AUTHORITY: E.O. 9397 and Department of Defense Financial Management Regulation (DoDFMR)
7000.14-R, Volume 7B, Chapter 26. PRINCIPAL PURPOSE(S): To appropriately withhold the State
income tax from the member's military retired pay as requested by the member. ROUTINE USE(S): The
information on this form may be disclosed as generally permitted under 5 U.S.C. Section 552(a)(b) of
the Privacy Act of 1974, as amended. It may also be disclosed outside of the Department of Defense
to the Internal Revenue Service to resolve matters relating to an individual's taxes. In addition, other
Federal, State, or local government agencies, which have identified a need to know, may obtain this
information for the purpose(s) identified in the DoD Blanket Routine Uses as published in the Federal
Register. DISCLOSURE: Voluntary; however, if the information is not provided, there may be a
significant delay in the processing of the request to withhold the State income taxes.
1. NAME (Last, First, Middle Initial)
2. SOCIAL SECURITY NUMBER
3. CURRENT RESIDENCE ADDRESS (Number and Street, City, State and ZIP Code)
4. AMOUNT FOR WITHHOLDING TAX (Must be $10.00 or
5. DESIGNATED STATE
$
more in whole dollars)
I hereby request that the above designated amount be withheld from my
retired pay account for State withholding tax purposes for the state indicated.
6. RETIREE'S SIGNATURE
7. DATE
DD FORM 2868, DEC 2003
REPLACES DFAS-CL FORM 7401/17
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