Shareholder Authorization to Withhold Federal Income Tax from
Dividends and Distributions
This form is to be used when a shareholder wishes to have federal income tax taken from their dividend or special distribution.
Please allow one month for processing.
Shareholder Name:
Date:
Social Security Number:
Birth Date:
Address:
Please select the appropriate box:
□
I hereby authorize The Tatitlek Corporation to withhold _____ percent federal income tax from my shareholder
dividends. This authorization will remain in effect until it is cancelled by submitting a completed form to the
Shareholder Services Department.
□
I would like to continue to receive the full value of my shareholder dividends, and understand that a certain
percentage of those dividends will be taxed each calendar year.
□
I hereby authorize The Tatitlek Corporation to withhold _____ percent federal income tax from my
elder distributions. This authorization will remain in effect until it is cancelled by a written notice
addressed to the Account Department.
□
I would like to continue to receive the full value of my elder distributions, and understand that a certain
percentage of those distributions will be taxed each calendar year.
Shareholder Signature:
Internal Use Only
Date:
Action taken:____________________________________________________
Date changed in CRM:_____________________________________________
Changed by: _____________________________________________________
PLEASE RETURN COMPLETED FORM TO:
THE TATITLEK CORPORATION
ATTENTION: Shareholder Services
561 East 36th Avenue
Anchorage, AK 99503