Form It-2104-P - Annuitant'S Request For Income Tax Withholding
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1IT-2104-P
New York State Department of Taxation and Finance
Annuitant’s Request for Income Tax Withholding
(8/11)
New York State • New York City • Yonkers
First name and middle initial
Last name
Your social security number
Permanent mailing address
Apartment number
Annuity contract claim or
( number and street or rural route )
identification number
City, village, or post office
State
ZIP code
Enter the whole dollar
1
1
New York State income tax ..................................................................
amount to be withheld
2
New York City income tax ( if a New York City resident ) .......................
2
from each annuity or
3
3
Yonkers income tax surcharge ( if a Yonkers resident ) ..........................
pension payment:
I request voluntary income tax withholding from my annuity or pension payments as authorized by section 671(b) of the Tax Law.
Signature of annuitant
Date
IT-2104-P (8/11) (back)
Instructions
Payee
Statement of income tax withheld
After the end of the year, your payer will give you federal Form 1099‑R,
Who may file
Distributions From Pensions, Annuities, Retirement or Profit‑Sharing Plans,
If you receive an annuity or pension payment that must be included in your
IRAs, Insurance Contracts, etc., showing the gross amount of annuity or
New York adjusted gross income, you may file this form to have New York
pension payments and the total amount deducted and withheld as tax during
State income tax (and, if a New York City or Yonkers resident, that city’s
the calendar year.
personal income tax) withheld from each payment. However, the annuity or
pension must be payable over a period longer than one year.
Payer
Keep this certificate with your records.
Where and how to file
See the instructions for Form NYS‑1, Return of Tax Withheld, and
File this form with the payer of your annuity or pension. Enter on the front
Form NYS‑45, Quarterly Combined Withholding, Wage Reporting, and
the whole dollar amount(s) that you want withheld from each annuity or
Unemployment Insurance Return, for payment and reporting requirements
pension payment. However, each amount must be at least $5 per month
for New York State, New York City, and Yonkers personal income taxes that
and should not reduce the annuity or pension payment you receive to less
you withheld from annuity or pension payments.
than $10. Quarterly payments of estimated income tax may be made in
I
, Instructions for
addition to or instead of withholding; see Form IT‑2105‑
Privacy notification
Form IT‑2105, for more information.
The Commissioner of Taxation and Finance may collect and maintain personal information pursuant to the New
York State Tax Law, including but not limited to, sections 5‑a, 171, 171‑a, 287, 308, 429, 475, 505, 697, 1096, 1142,
If you need help completing this form, call (518) 457‑5181.
and 1415 of that Law; and may require disclosure of social security numbers pursuant to 42 USC 405(c)(2)(C)(i).
This information will be used to determine and administer tax liabilities and, when authorized by law, for certain tax
Duration of withholding request
offset and exchange of tax information programs as well as for any other lawful purpose.
Your request for voluntary withholding will remain in effect until you terminate it.
Information concerning quarterly wages paid to employees is provided to certain state agencies for purposes
of fraud prevention, support enforcement, evaluation of the effectiveness of certain employment and training
How to terminate a withholding request
programs and other purposes authorized by law.
You may terminate your request for voluntary withholding by giving your
Failure to provide the required information may subject you to civil or criminal penalties, or both, under the Tax Law.
payer a written termination notice.
This information is maintained by the Manager of Document Management, NYS Tax Department, W A Harriman
Campus, Albany NY 12227; telephone (518) 457‑5181.
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