New York Form 8104 at a glance
What it is: Dividend Option Change, form 8104.
Where and when to file: Return the form to New York Life, P.O. Box 130539, Dallas, TX 75313-0539. The dividend option change will become effective on the current policy anniversary date, if this request is received by New York Life at least 31 days prior to the current policy anniversary date. Any requests received after this period will take effect on the next policy anniversary. Note: If your policy contains the Dividend Option Term rider, the dividend option must be Paid-up Additions. Whole Life Additions are only available for policies issued between issued between April 7, 1975 and February 1, 1988.
A filled-in New York Form 8104 example: an owner elects 10% federal and 5% state withholding
How to fill out New York Form 8104, box by box
Dividend Option Change
Enter the Policy Number and Name. Enter the Name if different than the Name under Insured Information and the Social Security or TAX ID (Required).
Section A is for policies with the One Year Term Option.
Select one box in Section A: cancel the ONE YEAR TERM Rider and apply dividends payable as elected in Section B.
Or retain the ONE YEAR TERM Rider, but change the option for the balance of dividends payable, as elected in the Check one list of Section A.
Section B is for policies without the One Year Term Option.
Check one: Provide Paid-Up Additions; Leave on deposit with New York Life to accumulate at interest; Apply to pay premium and any loan interest due and pay balance in cash*; Apply toward payment of premium only and pay balance in cash*; Pay in cash; or Provide Whole Life Additions.
Or select the box to change the current dividend option to cash and apply the cash dividend proceeds to pay policy loan interest due, then repay any policy loan on this policy. When any loan interest which is due and any policy loan has been repaid, the dividend method changes to provide Paid-up Additions. The dividend option marked * is available only when the mode of payment is one that has a premium falling due on the policy anniversary date.
Federal Withholding and State Withholding
(1) I would like to apply _____% of the taxable portion to Federal Withholding. (2) I would like to apply _____% of the taxable portion to State Withholding.
If you elect to have Federal Income tax withheld, at least 10% of the taxable portion of the distribution is required to be withheld.
If your state requires withholding, the state's minimum amount applies if you select an amount that is less than the minimum.
If you reside in any of the following states and request state tax withholding, you must also specify the percentage of state tax withholding that you choose to apply to the taxable portion of the withdrawal: Alabama, Colorado, Connecticut, District of Columbia, Idaho, Illinois, Indiana, Kentucky, Louisiana, Minnesota, Missouri, Montana, New Jersey, New Mexico, New York, North Dakota, Ohio, South Carolina, Utah, West Virginia, and Wisconsin. In these states, if a percentage is not specified, state tax will not be withheld.
Non-persons such as corporations, companies, trusts, etc. or U.S. citizens living outside the United States cannot elect out of withholding.
Signing as the policy owner
Policyowner's Signature (REQUIRED): sign on the Policy Owner Signature line and fill in Name (Printed) and Date.
Check this box if the IRS has notified you that you are subject to backup withholding.
Common questions about New York Form 8104
Where do I file it?
Return the form to New York Life, P.O. Box 130539, Dallas, TX 75313-0539.
Is there a penalty?
In addition, a 10% IRS penalty may be imposed if you receive the withdrawal prior to age 59½, unless you are disabled or some other exception applies.
What am I certifying when I sign?
Under penalties of perjury, I (as owner named) certify: (1) my social security number or Tax ID number shown on this form is my correct taxpayer identification number, (2) I am not subject to back withholding because (a) I am exempt from backup withholding; or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividend income; or (c) the IRS has notified me that I am no longer subject to backup withholding, (3) I am a U.S. person (includes a U.S. resident alien), and (4) I am exempt from Foreign Account Compliance Act (FATCA) reporting.
Sources
[1] New York Form 8104 (6/2016), Dividend Option Change, New York Life (the Official source link on this page).
