Application For A Disability Allowance Page 10
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12CT TEACHERS’ RETIREMENT BOARD
765 ASYLUM AVENUE HARTFORD, CT 06105-2822
An Affirmative Action/Equal Opportunity Employer
Toll-Free 1-800-504-1102 (860) 241-8400 Fax (860) 525-6018
FEDERAL AND CT TAX WITHHOLDING CHANGE FORM
Complete the federal or state section if you wish to change that election. If you wish to change only one election, leave the
other section blank. This change will remain in effect until we receive another form.
Print Your Name
Social Security Number
Address
City
State
Zip
Phone Number
Email Address
*
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FEDERAL TAX ELECTION
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Please select one option below:
1.
No withholding. I realize that I am liable for payment of Federal Income Tax on
my Teachers’ Retirement Benefit.
2.
I would like to have withholding calculated based on the following marital status and withholding
:
allowances
Check One:
Married
Single
Married, but withhold at higher Single rate
Withholding Allowances:
(TRB will code zero allowances if none is specified)
Optional for choice 2: I wish to have $
withheld from my monthly benefit payment in addition to the
withholding based on marital status and withholding allowances.
(Whole dollar amount only, percentages not acceptable)
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CONNECTICUT TAX ELECTION
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We can only withhold State taxes for the State of Connecticut. If you have any questions on your
Connecticut tax obligation, contact the Department of Revenue Services at 1-800-382-9463 (in CT) or
1-860-297-5962 (from anywhere) or visit their website @
1.
I elect to have $
withheld monthly for Connecticut Income Tax.
(Whole dollar amount only, percentages not acceptable)
I elect to have NO Connecticut income tax withheld from my Teachers’ Retirement benefit.
2.
Member’s Signature
Date
st
CTRB does not acknowledge the receipt of individual forms. CTRB must receive the completed form by the 1
of the month
in order for the change to be effective at the end of the month. (Benefits for the month are issued on the last business day of
that month.) We require that the net monthly amount payable to the member be at least $10 after all deductions.
FedCTtax (Rev. 01/2014)
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