F349
NYCERS USE ONLY
Mail completed form to:
or
30-30 47th Avenue, 10th Floor
Long Island City, NY 11101
www.nycers.org
Visit Client Services
340 Jay Street
Brooklyn, NY 11201-3724
(347) 643-3000
Federal Income Tax Withholding Change -- W-4P
M M
-
PENSION #
LAST 4
SSN
D D
-
DATE OF
BIRTH
Y
Y
Y
Y
MIDDLE
INITIAL
FIRST NAME
1
LAST NAME
ADDRESS
IS FOREIGN
ADDRESS
APT
CITY
DAYTIME
PHONE #
ZIP CODE
STATE
(
)
EMAIL
[Choose your tax-withholding option below. Place an X or a number in the box(es) to indicate your choice(s).]
DO NOT WITHHOLD TAX
2
[ Complete this section if you do not want NYCERS to withhold any
Federal income tax from your pension payments. If you check this
box, DO NOT COMPLETE Section 3 or 4 below. ]
DO NOT WITHHOLD FEDERAL TAX
OR
WITHHOLD TAX BASED ON EXEMPTIONS
Number of
3 allowances
(REQUIRED)
marital
status
SINGLE
(REQUIRED)
4
Additional
amount
(OPTIONAL)
[Enter total number of allowances (exemptions) and
your marital status. If you would like to withhold an
additional amount, enter the amount in Section 4 . ]
NUMBER OF ALLOWANCES YOU
ARE CLAIMING
OR
MARRIED
DOLLARS
ADDITIONAL AMOUNT TO
WITHHOLD PER MONTH
OR
MARRIED, BUT WITHHOLD AT
HIGHER SINGLE RATE
[ If you enter an amount
here, you must also complete
Section 3 above.]
CENTS
.
I have completed this form and represent that all information is true and accurate.
DATE
(MM/DD/YYYY)
SIGNATURE
This form must be acknowledged before a Notary Public or Commissioner of Deeds
State of
County of
On this
day of 20
, personally appeared before me the above
named,
, to me known, and known to me to be the individual described in and who
executed the foregoing instrument and he or she acknowledged to me that he or she executed the same, and that the statements
contained therein are true.
Signature of Notary Public or
Commissioner of Deeds
Official Title
Expiration Date of Commission
R 08/06/15
If you have an official seal, affix it
*349*
[Print clearly in CAPITAL letters. See reverse for information and instructions. ]
Information and Instructions
This form is for NYCERS pensioners and beneficiaries who wish to change the amount of Federal income tax withheld from
their monthly pension payments.
Print clearly in CAPITAL letters. Use black or blue ink only. Leave blank spaces between words and numbers.
1 2 3 4 5 6 7 8 9 0 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
1
If your address is foreign:
Put an ‘X’ in the box labeled "Address is Foreign" and enter the address as follows:
Address Field:
City:
Enter your street address or post office box number, City or Town, other principal subdivision
(e.g., province, state, county) and postal code, if known. (The postal code may precede the city or
town.).
Enter the entire country name in the City field.
State/Zip Code Fields: Leave these fields blank.
2
Select this option if you do not want NYCERS to withhold any Federal income tax from your pension payments.
If you check this box, DO NOT COMPLETE Section 3 or 4.
3
Enter total number of allowances (exemptions) and your marital status.
If you would like to withhold additional monies, enter the amount in Section 4.
4
If you enter an amount here, you must also complete Section 3.
Sign this form before a Notary and return it to NYCERS at the address shown. Keep a copy for your records.
Use this form to indicate to NYCERS the amount of Federal income tax to withhold. You may also use this form to choose:
(a) not to have any Federal income tax withheld from the payment, or (b) to have an additional amount of Federal income
tax withheld.
Pensioners with a MyNYCERS account and a registered Personal Identification Number (PIN) may log in at www.nycers.org
and change their tax withholding online instead of filing this paper form.
NYCERS cannot counsel you on tax matters. If you need assistance in determining which tax withholding selections to make,
please consult with a professional tax preparer or the Internal Revenue Service (IRS).
NOTE: If the address you provide on this form is different from your address in our system, the new address will become
your official address in our records.