A.Mandatory State Withholding: If you reside in a state where state income tax withholding is mandatory AR, CA*, DC (mandatory for total single sum distributions only), DE, IA, KS, MA, MD (mandatory for eligible rollover distributions only, subject to 20% mandatory federal withholding), CT, ME, Ml (see below), NC, NE, OK*, OR*, VA or VT* applicable withholding will be deducted automatically, unless an election out is applicable (see below). Note: Some states require withholding if federal income tax is withheld from the distribution.
If you are a resident of IA, have federal income taxes withheld, and receive one or more distributions totaling more than $6,000 in the calendar year, IA income taxes are required to be deducted for the amount over $6,000.
□My resident state is AR, DE, KS, ME, NC, NE, or VA (for NE and VA, election out is allowed for payments from IRA’s only) and I do not want state income tax withholding deducted from my distribution. (An election out of AR, DE, KS, ME, NC, or VA state tax is not allowed for eligible rollover distributions, subject to 20% mandatory federal withholding ) Important note to Maine (ME) residents. If you elect out of ME withholding, you must either have elected out of federal withholding, or have no Maine State tax liability in the prior or current years.
□*My resident state is one of the following: CA, OK, OR, **VT and withholding is required if federal income tax is withheld, unless I elect out of state withholding. By checking this box I am electing out of state withholding. **An election out is not allowed for eligible rollover distributions, subject to 20% mandatory federal withholding.
□My resident state is CT and Prudential will withhold 6.99% on your taxable distribution. Please note that if you are not requesting a distribution of your entire account balance and if Form CT-W4P, Withholding Certificate for Pension or Annuity Payments, applies to you, please return Form CT-W4P as part of this distribution form. Form CT-W4P is available on the Department of Revenue Services (DRS) website, at www.ct.gov/DRS.
My resident state is Ml and withholding of 4.25% is required, unless my payments are not taxable and I opt out.
□My resident state is Ml and I would like to opt out of Ml withholding. Note: Opting out may result in a balance due on your Ml 1040 as well as penalty and/or interest.
□My resident state is Ml and if my payments are taxable, I wish to have Ml state withholding based on the number of exceptions selected. I have entered the number of exemptions below:
________ Enter the number of personal exemptions allowed on your Michigan Income Tax Return (Ml-1040). The total number of exemptions you claim may not exceed the number of exemptions you are entitled to claim when you file your MI-1040. Withholding will be computed at the percentage determined by the state after subtracting your personal exemption allowances.
□My resident state is Ml and I am requesting________ % additional Ml state tax withheld from my payment. This amount must be a whole percentage.
B.Voluntary State Withholding: Please check the appropriate box below. If state income tax withholding is not mandatory in your state, you may be allowed to request state tax withholding. If your state of residence is not listed, or if you choose a method of withholding that is not offered for your state, we cannot withhold state income tax.
□I reside in one of the following voluntary withholding states: AL, CO, DC (voluntary for partial and systematic distributions), GA, ID, IA (voluntary if no federal tax withheld) IL, IN, KY, LA, MD (non- eligible rollover distributions only), MA (voluntary if no federal income tax withheld), MN, MO, MS (voluntary except for early distributions), MT, ND, NE, NJ, NM, NY, OH, PA, Rl, SC, UT, VA, Wl, WV (NE and VA state withholding is voluntary for payments from IRA’s only) and would like state income tax withheld. (Specify a percentage or dollar amount to be withheld.)
______________ % or $___________________
□I reside in one of the voluntary withholding states listed above and I do not want state income tax withholding deducted from my distribution.
C.No State Withholding: Some states do not have state income tax withholding.
□My resident state is one of the following: AK, FL, HI, NV, NH, SD, TN, TX, WA, WY and there is no state income tax withholding.
□My resident state is AZ and there is no state income tax withholding on non-periodic (single sum) payments.