Brockton Retirement Board
15 Christy’s Drive, Suite 2
Brockton, MA 02301-1813
brockret@comcast.net
RETIREE’S WITHHOLDING PREFERENCE CERTIFICATE
FORM W-4P
Name: ___________________________________________________
Address: ________________________________________________
________________________________________________________
________________________________________________________
PLEASE CHECK THE APPROPRIATE BOX:
_______ I do not wish to have Federal Tax withheld from my benefit.
I realize that I am liable for payment of Federal income tax
on the taxable portion of my pension and that I may be
subject to tax penalties under the estimated tax payment
rules if my payments of estimated tax and withholding are
not adequate.
_______ The following exemptions are being claimed and I wish to have
the Plan Administrator determine the amount, if any, of Federal
income tax to be withheld in accordance with the tax tables and
exemptions claimed below.
Marital Status:
_____Single ______Married ______Married, but
Withhold at a higher
Single rate
Total exemptions you wish to claim:_________
_______ I wish to have $____________per month withheld.
SIGNATURE OF RETIREE: