Request For Income Tax Withholding - Arlingtonva
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2REQUEST FOR INCOME TAX WITHHOLDING
ARLINGTON COUNTY EMPLOYEES’ SUPPLEMENTAL RETIREMENT SYSTEM
2100 CLARENDON BOULEVARD – SUITE 511
ARLINGTON, VIRGINIA 22201
TELEPHONES: (703) 228-3500, (800) 818-4910 FAX (703) 228-3265
Complete this form if: (1) You are a new retiree, or (2) you want to make a change to your income tax withholding. If a completed
tax withholding form is not on file, we will withhold federal income tax based on the rate for a married individual claiming three
exemptions and state income tax based on the rate for zero exemptions.
PART A. RETIREE INFORMATION
1. Name
(First
(MI)
(Last)
(Jr./Sr.)
)
2. Address
(Street)
(City)
(State) (Zip)
3. Last Four Digit of Social Security Number
4. Telephone Number
XXX-XX- ___ ___ ___ ___
PART B. FEDERAL INCOME TAX WITHHOLDING
Choose one option below. If you choose to have income tax withheld, provide your marital status and the number of exemptions.
Do not withhold federal income tax from my monthly benefit. I understand that I am liable for payment of
federal income tax on the taxable portion of my benefit and that I may be subject to tax penalties under the
estimated tax payment rules if my payment(s) of estimated tax and withholding are not adequate. (If you are
a U.S. Citizen or resident alien and your monthly benefit payments are delivered outside the U.S. or its
possessions, you must have federal income tax withheld.)
Using the marital status and the exemptions below, calculate my federal income tax withholding (if any) in
accordance with the tax formula as published in IRS Publication 15.
Marital Status:
Married
Single
Married, but withhold at higher Single Rate
Number of Exemptions: _________________
If you wish an amount withheld in addition to the calculated tax, enter the additional amount to be withheld
per month: $ _________________
Instead of calculating my federal income tax, I elect a voluntary withholding per month in the amount of
$ _____________________.
PART C. STATE OF VIRGINIA INCOME TAX WITHHOLDING
Choose one option below. If you choose to have state income tax withheld, provide the number of exemptions of each type.
(You are not required to have Virginia state income tax withheld from your benefit if you do not reside in Virginia.)
Do not withhold state income tax from my monthly benefit. I understand that I am liable for payment of state
income tax on the taxable portion of my benefit and that I may be subject to tax penalties under the
estimated tax payment rules if my payment(s) of estimated tax and withholding are not adequate.
Using the exemptions below, calculate my state income tax withholding (if any) in accordance with the tax
formula as published in the Virginia Income Tax publication.
Personal Exemptions: _______ Age and Blindness Exemptions: _______ Total Exemptions: _______
If you wish an amount withheld in addition to the calculated tax, enter the additional amount to be withheld
per month: $ _________________
Instead of calculating my state income tax, I elect a voluntary withholding per month in the amount of
$ _____________________.
SIGNATURE __________________________________ DATE _________________________
C:\Documents and Settings\bgrowd\Local Settings\Temporary Internet Files\OLK11F\Form - REQUEST FOR INCOME TAX WITHHOLDING.doc
Rev. 05/09
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