State Income Tax Withholding Form
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1
2Caring For Those Who Serve
1901 Chestnut Avenue
Glenview, Illinois 60025-1604
1-800-851-2201
State Income Tax Withholding Form
Important:
•
If your state of residence is different than the state in your mailing address, complete Part 2 of this form so that we can apply
the appropriate state income tax withholding rules.
If you are a resident of AK, FL, NH, NV, SD, TN, TX, WA or WY, we cannot apply state withholding as these states do not
•
have personal income tax laws. Do not complete this form unless Part 2 applies.
•
If you are a resident of CA, ME, MI or OR and you do not make a state withholding election or you do not make an election
for “no state withholding,” we will apply state withholding.
If you are a resident of GA and you are receiving a partial distribution, lump sum distribution, required minimum
•
distribution or hardship withdrawal, and you do not make a state withholding election, we will not apply state
withholding.
•
If you are a resident of GA and you are receiving cash installments or a term annuity lasting for periods of 10 years or
more or a life annuity, and you do not make a state withholding election, or you do not make an election for “no state
withholding,” we will apply state withholding.
If you are a resident of AR, DE, IA, KS, MA, MD, NC, NE, OK, VA or VT, and you do not make a state withholding
•
election or you do not make an election for “no state withholding,” we will apply state withholding on your distribution
if Part 3 or 5 applies. State withholding is mandatory on your distribution if Part 4 applies.
•
If you are a resident of the District of Columbia and you are receiving a lump sum distribution, we will apply state
withholding.
•
If you are a resident of MS and you are receiving a distribution that would qualify as an early distribution with no known
exception as defined in Internal Revenue Code Section 72, we will apply state withholding.
•
If you are a resident of any state other than those listed above, we will not apply state withholding. Do not complete this
form unless Part 2 applies.
For more information, check with your state department of revenue or a tax advisor.
Part 1 – Participant Information
Name
Social Security #
_____________________________________________________________________________________
________________________
(
)
Mailing address
Primary phone #
__________________________________________________________________________
________________________
E-mail
_____________________________________________________________________________________________
___________________________________
Country of citizenship
___________________________________________________________________
Part 2 – State of Residence*
State of residence for tax purposes (enter state name, if different from mailing address):
_____________________________________________________________________________________________
* Note: If you move and your state of residence changes, you must submit a new State Income Tax Withholding Form
to the General Board of Pension and Health Benefits.
3421/081315
(over)
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