Annuitants Request For State Income Tax Withholding {WH-4P}

Form WH-4P State Form 37365 (R1/ 3-05) State of Indiana Annuitant's Request for State Income Tax Withholding (Please Type or Print Clearly) Full Name Home Address (number and street) City, State, and Zip code A. Annuity contract claim or identification number........................................................................................ A. B. Enter the amount of Indiana tax to be withheld from each annuity or pension payment.......................... B. $ I request voluntary income tax withholding from my annuity or pension payments. Signature of Annuitant Social Security Number Date American LegalNet, Inc. www.FormsWorkflow.com You may select any amount over $10.00 to be withheld from your annuity or pension payment. This withholding will be reported to you on a W-2P at the end of each year as Indiana Tax Withheld. Indiana county tax cannot be withheld. However, if you overpay your state income tax and have additional state tax withheld, this overpayment may be applied to your county income tax. A. Enter the Contract, Policy, or Account Number to which the request applies. B. Enter an amount, not to be less than $10, that you wish to have withheld from each check. Send this form to the person or company paying your pension. Do not send this to the Department of Revenue. American LegalNet, Inc. www.FormsWorkflow.com