Free 53466.pdf - Indiana

Indiana State Teachers' Retirement Fund 150 West Market St., Suite 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 / (888) 286-3544 Website: www.in.gov/trf

INDIANA STATE INCOME TAX WITHHOLDING FOR LUMP SUM DISTRIBUTION
State Form 53466 (12-07) Approved by State Board of Accounts, 2008

PRIVACY NOTICE
Your Social Security Number is being requested pursuant to IRS Code 3405. Disclosure is mandatory and this document cannot be processed without it.

MUST USE BLACK OR BLUE INK This form is optional. If you elect to receive a lump sum distribution of your Annuity Savings Account (options ASA 2 or ASA 4) and would like to have Indiana State Income Tax withheld from your distribution, please complete this form. The Indiana State Income Tax Rate is 3.4%. The 3.4% rate does not include county tax.
Full name Social Security number

Street address

TRF number

City

State

ZIP code

Telephone number ( ) -

I authorize the Indiana State Teachers' Retirement Fund to withhold the following dollar amount for Indiana State Tax Withholding from my lump sum distribution:

$

I hereby request voluntary Indiana State Income Tax Withholding from my lump sum distribution of my Annuity Savings Account. Signature Date (month, day, year)

Please consult a qualified tax professional if you have any questions regarding the tax status of your retirement income.