Withdrawal and Tax Withholding Election Form: Traditional IRA, Roth IRA or SEP-IRA

Withdrawal and Tax Withholding Election Form:

Traditional IRA, Roth IRA or SEP-IRA

This form may be used to request a withdrawal from your Traditional IRA, Roth IRA or SEP-IRA

This form cannot be used for the following:

• To transfer your IRA to another institution. Please obtain a transfer form from the new institution.

• For distributions due to death, please complete a Withdrawal and Tax Election Form for Beneficiaries.

Converting a Traditional IRA to a Roth IRA

• Please attach a completed Citibank Roth IRA Application Form to a completed Withdrawal and Tax Withholding

Election Form. If you already have a Citibank Roth IRA, please use the Roth IRA Contribution Form to convert from a

Traditional IRA to a Roth IRA.

• If a completed Roth IRA Application Form (or Roth IRA Contribution Form) does not accompany the Withdrawal and

Tax Withholding Election Form, the funds from the Traditional IRA will be distributed to you, and you must contribute

them to a Roth IRA within sixty (60) days of receipt as a conversion contribution.

• If you wish to transfer your IRA to another institution, please obtain a transfer form from that institution.

When completing this form, be sure to include the following:

• Complete Name and Residential Address

• Social Security Number

• Date of Birth

• Type of Plan (Traditional IRA, SEP-IRA or Roth IRA)

• Type of Withdrawal

• Account Number(s)

• Signature and Date

• Please use page 6 of this form to provide a notarized signature for withdrawals above $10,000

• Please use page 6 of this form to provide a notarized signature for accounts established within the last 30 days

• Complete the included IRS Form W-4R. (Your prior withholding election will remain in force If your Form W-4R

is not provided.)

• If your tax status has changed please be sure to attach either a IRS Form W-9 or IRS Form W-8BEN to this form

To cancel a scheduled IRA contribution from your Citibank account

• Please use page 3 if scheduled IRA contributions are currently being deducted from your Citibank checking account,

and you would like to cancel that schedule.

When returning this form by mail, please mail to:

Retirement Plan Services

P.O. Box 769001

San Antonio, TX 78245-9951

If you have any questions

Call Retirement Plan Services at 1-800-695-5911.

For TTY: We accept 711 or other Relay Service. Representatives are

available to assist you Monday through Friday 8:00 a.m. – 10:00 p.m. Eastern Time, and Saturday 9:00 a.m. – 5:30 p.m.

Eastern Time.

* To ensure quality service, calls are recorded

Customer Initials

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01/24 RPS508 Page 1 of 6

Withdrawal and Tax Withholding Election Form

Plan Owner Information

You must complete Sections 1-6 to avoid delays with your process.

Please type ”N/A” when not applicable.

1. Plan Owner Information (Must Complete)

First Name: __________________________Middle: _____________________________ Last Name: _______________________________

Date of Birth: (mm/dd/yyyy):_______________________________________________

Identification

Type: _____________________________________________ID Number: _______________________________ State: __________________

Issue Date: ______________________ Expiration Date: ___________________________

Residential Address  Check if new address (If less than one year in address, please provide Prior Residential

Address below)

Street Address: _______________________________________________________________________ Apt. Number: _________________

City: ________________________________ State: __________________________ Zip: ______________Country:_____________________

Address since: ______________________

Prior Residential Address

Start Date: _________________________ End Date: ______________________

Street Address: _______________________________________________________________________ Apt. Number: _________________

City: ________________________________ State: __________________________ Country: _____________________ Zip: _____________

Mailing Address (if different from Residential Address)

Street Address: _______________________________________________________________________ Apt. Number: _________________

City: ________________________________ State: __________________________ Country: _____________________ Zip: _____________

Phone Number (Please provide one)

Home: _______________________________Business: ___________________________ Mobile: ___________________________________

If you provide us a mobile number or number later converted to a mobile number, you agree that Citibank or our service

providers may contact you at that number about your Banking Accounts, including loans and lines of credit. This

consent allows us to use text message, artificial or pre-recorded voice messages and automatic dialing technology for

informational and account service calls, but not telemarketing calls. Message and data rates may apply. Contact us

anytime to opt-out.

Email Address (Please provide one)

Primary: __________________________________________ Secondary: ________________________________________

 I prefer not to provide or do not have an email address.

Security Questions: Mother ’s Maiden Name:___________________________First School Attended:_______________________________

Customer Initials

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01/24 RPS508 Page 2 of 6

Withdrawal and Tax Withholding Election Form

Withdrawal Information

Tax Reporting Information

 I am a U.S. Person (a U.S. citizen or resident alien). My Social Security Number is : __________________________________

 I am a Non-U.S. Person (a nonresident alien). My Foreign Tax Identification Number (FTIN) is : ______________________

 My status as a U.S. Person or non-U.S. Person has changed (If there has been a change in tax status or change in

circumstances, you may be required to submit an updated U.S. tax certification Form W-9

or Form W-8BEN

)

My country of tax reporting is __________________________________ (If U.S. Citizen or resident alien, please complete

Form W-9

Important: Non-US Persons are generally subject to a 30% withholding tax on the amount of their withdrawal. A

reduced rate may apply if you have provided a Form W-8BEN

making a valid treaty claim, and reside in a country

whose treaty provides for a lower withholding rate.

IRS Form W-9 can be found online by visiting: https://www.irs.gov/pub/irs-pdf/fw9.pdf and

IRS Form W-8BEN can be found online by visiting https://www.irs.gov/pub/irs-pdf/fw8ben.pdf

2. Type of Plan

Indicate the type of plan from which you are taking a withdrawal (select one below):

 Traditional IRA  Roth IRA  SEP-IRA  Rollover IRA  Roth Rollover IRA

Important Information:

IRA One-rollover-per-year rule: You generally may not perform more than one IRA-to-IRA rollover within a 1-year period

(365 days). This limitation applies no matter how many IRAs you own. The 1-per year limit does not apply to rollovers into

IRAs of amounts distributed from employer plans.

60-day rollover period: If a distribution from an IRA or a retirement plan is paid directly to you, you can deposit all or a

portion of it in an IRA or a retirement plan within 60 days. Federal and, in certain cases, state withholding taxes will be

withheld from a distribution from a retirement plan.

Type of Withdrawal (Please select one):

 Regular Distribution

 Conversion to Roth IRA  Premature Distribution

 Recharacterization to a SEP-IRA  Charitable Distributions  Direct Rollover to Employer Plan

 Recharacterization to an IRA  Recharacterization to a Roth IRA

 Remove Excess Contribution

 For Prior Year  For Current Year

 To remove earnings attributable to an excess contribution

 Qualified Birth or Adoption Distribution — you may withdraw up to $5,000 for the birth or adoption of a child without

incurring the usual 10% additional tax applicable to early distributions. The distribution must be made within one

year after the child is born or the adoption is finalized. You may generally recontribute any portion of the distribution

as a rollover contribution within 3 years of the date the distribution was received (for distributions received after

December 29, 2022).

After age 59½

Before age 59½; may be subject to a 10% IRS tax penalty

Customer Initials

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01/24 RPS508 Page 3 of 6

Withdrawal and Tax Withholding Election Form

One-Time Withdrawal:

Select withdrawal Schedule: Select Withdrawals:

 Immediate  Withdraw my total plan balance

 At Maturity  Withdraw my total balance from the Insured Money Market (IMMA)/or Certificate of

Deposit (CD) account(s) number___________________________ ____________________________

 Future Date _____________________________

 Withdraw this amount (specify) $ ________________________ from the IMMA/CD account

______________________________ (specify account number as listed on your statement).

Scheduled Distributions:

Select withdrawal Schedule: Select Withdrawals:

 Monthly  Interest only

from IMMA/CD account number(s) (specify): ______________________

 Quarterly  Withdraw this amount (specify) $_______________________

 Semi - Annually from the plan number as listed on my statement________________________

 Annually

Auto Deduct from Citibank accounts:

 Please check here if scheduled IRA contributions are currently being deducted from your Citibank checking account,

and you would like to cancel that schedule.

The transfer or distribution of the entire balance in your Citibank IRA, Roth IRA, or SEP-IRA terminates your plan and Citibank's

responsibility as custodian. Terminated plans cannot be re-established and additional contributions will not be accepted for a

terminated plan. You will receive one additional summary statement for the year the plan is terminated.

Interest Only refers to the interest earned on your Insured Money Market (IMMA) account or Certificate of Deposit (CD).

3. Federal and State Income Tax Withholding

Please review and complete Attachment (A): Citibank IRA Tax Withholding Election Change Authorization for Periodic

Withdrawals/Distributions at the end of this form. Important: Non-U.S. Persons are generally subject to a 30%

withholding tax on the amount of their withdrawal. A reduced rate may apply if you have provided a Form W-8BEN with a

valid treaty claim with a country that provides for a lower withholding rate.

• Please review and complete the attached IRS form W-4R.

4. Method of Payment

Make deposit(s) to my Citibank (Please Select One)

 Checking Account Number_________________________

 Money Market Account Number _____________________

 Savings Account Number____________________

 Please mail a check to the address listed in Section 1.

Customer Initials

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01/24 RPS508 Page 4 of 6

Withdrawal and Tax Withholding Election Form

5. Tax Certification and Acceptance

Please select and certify the option which applies to your tax status, and that you have enclosed the applicable tax form

to validate your tax status.

I certify my tax status as:

 A U.S. Citizen living in the United States

 A U.S. Citizen living abroad

 A Resident Alien living in the United States

 A Resident Alien living abroad

 A Non-U.S. Person (a nonresident alien) *

* If you are a Non-U.S. Person, all IRA distributions are subject to 30% U.S. tax withholding unless a reduced treaty

rate is available. A W-8BEN must be completed if a valid form is not on file.

If you are a U.S. Citizen living abroad, or otherwise receiving a distribution outside of the U.S., Federal withholding

will default to 10% of the IRA distribution. You may not opt out. State withholding may also apply.

For Non-U.S. Persons — Withholding will default to 30% of the IRA distribution unless you have provided a Form

W-8BEN making a valid treaty claim, and reside in a country whose treaty provides for a lower rate.

► Signature:___________________________________________________________________ ► Date: _______________________________

6. Authorization, Certification and/or Acknowledgment:

• I have read and understand all the information provided and as outlined in this form.

• I authorize and direct Citibank to make a withdrawal from the above Citibank IRA in the manner and for the

reason indicated;

• I affirm that the withdrawal is permitted under the Citibank IRA and meets all legal requirements in the Internal

Revenue Code.

A notarized signature is required for withdrawals above $10,000, or accounts established within 30 days of

withdrawal request.

► Signature:___________________________________________________________________ ► Date: _______________________________

01/24 RPS508 Page 5 of 6

Withdrawal and Tax Withholding Election Form

A notarized signature is required for withdrawals above $10,000, or accounts established within 30

days of withdrawal request. If applicable, use the appropriate acknowledgment below.

California Only

Acknowledgment

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the

document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of California

County of___________________________________________

On__________________________________ before me, __________________________________________personally appeared

(date) (here insert name and title of the officer)

_____________________________________________________ who proved to me on the basis of satisfactory evidence to be

the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the

same in his/her authorized capacity, and that by his/her signature on the instrument the person, or the entity upon

behalf of which the person acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the state of California that the foregoing paragraph is true

and correct.

WITNESS my hand and official seal.

Notary Public Signature Notary Public Seal

All States Except California

Acknowledgment

State of __________________________________________________

County of_________________________________________________

On_______________________________ before me personally appeared, ________________________________________________

(date)

personally known to me or proved to me on the basis of satisfactory evidence (Type of Identification

produced_________________________________________________) to be the individual whose name is subscribed to the

within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her

signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the

instrument.

______________________________________________Notary Public Signature

______________________________________________Notary Public Printed Name (Notary Public Seal)

Branch Use Only:

A copy of this form must be placed in a branch transmittal envelope and sent to RPS Operations. Check the box below if

the distribution request was processed through NBS.

 Distribution request processed through NBS.

Note: To ensure proper processing, branches should contact RPS Branch Support.

Customer Initials

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01/24 RPS508 Page 6 of 6

ATTACHMENT A:

Citibank IRA Tax Withholding Election Change Authorization

for Scheduled Withdrawals/Distributions

Plan ID # _______________________________________________________________________

First and Last Name: ____________________________________________________________

Address Line 1: __________________________________________________________________

Address Line 2: _________________________________________________________________

City, State and Zip: _____________________________________________________________

Please complete the following election for Federal and, where applicable, state tax withholding for scheduled

withdrawals/distributions from your Citibank IRA. If you are changing your Federal withholding election (or had

not previously provided one), please also complete the enclosed Form W-4R.

Federal

Please only check one of the options below to select your federal tax withholding option:

 Do not withhold Federal Income Tax (applicable to my scheduled withdrawal).

 Withhold Federal Income Tax at 10% on my scheduled withdrawal.

 Withhold Federal Income Tax at the percentage indicated: ____________________ %

(in whole percentages).

State Tax Withholding

Please refer to the information on the pages that follow for default withholding details and follow your state of

residence requirements:

 Connecticut Resident, the State of Connecticut requires you to complete Form CT-W4P for periodic payments only.

For Non-periodic payments, the CT W4P is required only by those claiming Exemption with Code E. For married

filing jointly, Code E only applies if the expected combined annual gross income is less than or equal to $24,000; for

single filers Code E only applies if expected annual gross income is less than or equal to $15,000.

 I reside in one of the following states (Georgia, Indiana, Montana, New Jersey, New Mexico, Maryland, Utah, or

Wisconsin) and I elect ______ % or $ _________________________ amount to be withheld (please refer to the minimum

amount that can be withheld for your state).

 I reside in one of the following states (California, Georgia, Indiana, Maryland, Michigan, Minnesota, Montana,

New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, or Utah) and I am providing the state required Form

to request withholding or to opt out of state withholding. (Please refer to the minimum amount that can be withheld

for your state).

 I am opting out of, or claiming exemption from state withholding. I reside in one of the following states and I am

providing the applicable Form required by my state (Arkansas-AR-4P, California-DE-4P, Connecticut-CT-W4P,

Indiana-WH-4P, Iowa IA W-4P, Kansas- K-4, Maine W4-ME, Michigan-MI W-4P, Mississippi-Form 89-350,

Montana-MW-4, New Jersey-NJ-W-4P, North Carolina NC-4P, or Oregon-OR-W-4).

* States with no specific state form, use Federal W-4R

Please sign and date below to authorize your tax withholding change, along with state specific form, if required, and

mail to: Citibank, N.A, Attn: Retirement Plan Services, PO Box 769001, San Antonio, TX 78245

For overnight delivery, send to: Citibank, N.A, Attn: Retirement Plan Services, 100 Citibank Drive, San Antonio, TX 78245

Signature _______________________________________________________ Date _________________________________________

01/24 Page 1 of 5

Withholding for Federal and State Income Tax

Effective Immediately.

This document contains important tax information on Federal and State income tax withholding.

Please read and keep this document with your important records.

Federal Tax Withholding Options

If you choose federal tax withholding, Citibank will withhold either the percentage that you specified or 10% of the

withdrawal/distribution amount. If you are changing your Federal withholding election (or had not previously provided

one), please also complete the enclosed Form W-4R. If you elect not to have federal tax withholding apply to your

periodic or non-periodic withdrawals/distributions, or have insufficient tax withheld, you may be responsible for

payment of estimated tax. Please speak with a tax advisor for more information.

Important: Non-US Persons are generally subject to a 30% withholding tax on the amount of their withdrawal. A reduced

rate may apply if you have provided a Form W-8BEN with a valid treaty claim with a country that provides for a lower

withholding rate.

State Tax Withholding Options for Withdrawals/Distributions

The state withholding and/or election requirements may be applicable to withdrawals/distributions you take. If federal

income tax is withheld, some states also require mandatory withholding. Your state of residence based on your address

on record will determine your applicable state income tax withholding requirements. These requirements are subject

to change from time to time. Any change of address becomes effective the business day following notification. It is

your responsibility to inform us in writing if your address of record has changed to ensure we are applying the correct

tax withholding requirements. Check with your tax advisor for the most current state requirements applicable to your

withdrawal/distribution.

State Tax Details State of Residence

State tax withholding is mandatory

if payments are made outside the

U.S., if an incorrect tax identification

number (TIN) has been provided,

if the form is incorrect, or if you

requested federal tax withholding

and are a resident of:

Delaware (DE): Federal form W-4R may be used to request state withholding.

Nebraska (NE): Withholding applies to non-premature withdrawals/

distributions only. No withholding if elect to be out of federal withholding.

Use Form W-4N.

North Carolina (NC): Must withhold if there is: no TIN or an incorrect TIN.

State has own its rules: Arkansas (AR): Withholding applies to taxable portion of IRA distributions.

Specific dollar amounts cannot be designated unless as an additional

amount to be withheld designated on line 4 of AR 4P. First $6,000 per year of

qualified traditional IRA distributions may be excluded from w/h if exemption

is claimed on AR 4P.

Connecticut (CT): Mandatory for payers with an office or business in CT or a

payer that makes distributions of taxable pensions or annuities to CT resident

individuals, even if there is a federal election in place not to withhold. W/h only

applies to taxable portion of distribution. Electing out is not an option.

District of Columbia (DC): Mandatory on certain lump-sum distributions

(entire account balance payment) of any retirement plan, including IRAs.

Mississippi (MS): Withholding applies to premature and excess distributions.

Form 89-350 is used to calculate withholding.

01/24 Page 2 of 5

State Tax Details State of Residence

If federal tax is withheld, state tax

will automatically be withheld if you

are a resident of one of the following

states:

Delaware (DE): If withholding is not federally required, withholding is upon

payee election. May elect state withholding even if elected out of Federal

withholding. Use Federal form W-4R.

Iowa (IA): An election out of federal withholding will eliminate Iowa

withholding. Use form IA W-4P to elect back into state withholding.

Kansas (KS): May elect state withholding (with K-4, periodical payments

only) if elect out of Federal withholding.

Maine (ME): If there is 10% flat withholding rate federally on non-periodic

payments (including IRA distributions), the payor must withhold Maine tax at

5% rate. Form W4-ME is needed to elect out of ME withholding, or to elect to

have ME withholding if the payee elected out of federal withholding.

Massachusetts (MA): May elect state withholding with Form M-4P.

Missouri (MO): Follows federal guidelines for lump sum and periodic

distributions.

Nebraska (NE): Withholding applies to non-premature withdrawals/

distributions only.

North Carolina (NC): May use Form NC-4P to opt out of state withholding

when federal is required, or to elect state withholding when federal w/h does

not apply.

Oklahoma (OK): If there is federal withholding, then state withholding is

required; but payees can opt out for OK purposes even if federally withheld.

OK withholding can still be elected even if no federal withholding. Use Form

OK-W-4-R.

Vermont (VT): VT withholding even if payee elects optional federal

withholding and does not specifically state the payment is exempt from VT

withholding. If opt for no withholding, use Federal form W-4R.

If you are a resident of one of

the following states and do not

specifically opt out of state tax

withholding, state tax withholding

is mandatory and will be applied:

California (CA): Mandatory for California residents only. Form DE-4P is preferred.

Michigan (MI): Withholding only necessary for non-qualifying pension and

retirement benefits and qualifying private pension distributions that exceed

the pension limits for recipients born before 1946. Use Form MI-W4P to opt

out of withholding.

Minnesota (MN): A financial institution must withhold MN income tax on any

periodic or non-periodic pension distribution for MN residents unless the

payee requests that the financial institution not withhold. This includes IRA

distributions.

North Carolina (NC): Cannot opt out if no TIN or incorrect TIN. Use NC-4P or

a form with same provisions.

Oregon (OR): Use form OR-W-4 to opt out of withholding.

01/24 Page 3 of 5

State Tax Details State of Residence

If you request state tax withholding,

Citibank must withhold state tax.

You must specify the amount in

whole dollars not less than $10 in

the following states:

Indiana (IN): Payee specifies a flat, whole dollar withholding amount ($10

minimum). Use Form WH-4P.

Montana (MT): Use Form M-W4 only.

New Jersey (NJ): Use NJ-W-4P or use a form with the same provisions.

New Mexico (NM): May use federal Form W-4P if clearly labeled as being

used for purposes of New Mexico withholding.

If you request state tax withholding,

Citibank must withhold state tax in

the following states:

Georgia (GA): Withholding may be elected for non-periodic distributions

from a pension, annuity, or similar fund. Remains in effect until revoked.

Amount withheld should not be less than amount which would be required to

be withheld if it were a payment of wages by employer. Use Form G-4P.

Maryland (MD): A whole dollar amount of at least $5/month to be withheld if

elected to do so. Use Form MW507P.

Wisconsin (WI): Once recipient requests it, withholding becomes mandatory

on the part of the payer ($5 minimum).

Utah (UT): No specific state form. Payee election of state withholding makes

withholding mandatory. State has confirmed that distributions from an

individual retirement account are included under the meaning of “pension.”

Required State Specific Forms by State

States with no specific state form, use Federal Form W-4R

State Form URL for Download

Delaware (DE)

New Mexico (NM)

Utah (UT)

Vermont (VT)

Wisconsin (WI)

Federal Form

W-4R

https://www.irs.gov/pub/irs-pdf/fw4r.pdf

If you are a resident of the following states, and a state form is required to opt out of or claim exemption from withholding or

is otherwise required by the state.

State Form URL for Download

Arkansas (AR) AR-4P https://www.dfa.arkansas.gov/images/uploads/incomeTaxOffice/AR4P2022_FI.pdf

California (CA) DE-4P https://www.edd.ca.gov/pdf_pub_ctr/de4p.pdf

Connecticut (CT) CT - W4P https://portal.ct.gov/-/media/DRS/Forms/2022/WTH/CT-W4P_1222.pdf

Georgia (GA) G-4P https://dor.georgia.gov/documents/g-4p-withholding-certificate-pension-or-

annuity-payments

Indiana (IN) WH-4P https://www.in.gov/isp/files/WH-4P-Annuitants-Request-for-State-and-

County-Income-Tax-Withholding.pdf

Iowa (IA) IA W-4P https://tax.iowa.gov/sites/default/files/2022-12/2023IAW-4P%2844020%29.pdf

01/24 Page 4 of 5

State Form URL for Download

Kansas (KS) K-4

(K-4 is needed

for periodic

payments

only)

https://www.ksrevenue.org/pdf/k-4.pdf#search=K-4

Maine (ME) W4-ME https://www.maine.gov/revenue/sites/maine.gov.revenue/files/inline-files/23_

form_w-4me_ff.pdf

Maryland (MD) MW 507P https://www.marylandtaxes.gov/forms/22_forms/MW507P.pdf

Massachusetts

(MA)

M-4P http://www.mass.gov/dor/docs/dor/forms/wage-rpt/pdfs/m-4p.pdf

Michigan (MI) MI-W4P https://www.michigan.gov/documents/taxes/4924_365368_7.pdf

Minnesota (MN) W-4MNP https://www.revenue.state.mn.us/sites/default/files/2023-08/w-4mnp.pdf

Missouri (MO) MO W-4P https://dor.mo.gov/forms/MO%20W-4P_2019.pdf

Mississippi (MS) Form 89-350 https://www.dor.ms.gov/sites/default/files/Business/89350228.pdf

Montana (MT) MW-4 https://mtrevenue.gov/publications/montana-employees-withholding-

allowance-and-exemption-certificate-form-mw-4/

Nebraska (NE) W-4N https://revenue.nebraska.gov/sites/revenue.nebraska.gov/files/doc/tax-forms/f_

w4.pdf

New Jersey (NJ) NJ-W-4P http://www.state.nj.us/treasury/taxation/pdf/current/njw4p.pdf

North Carolina NC-4P https://www.ncdor.gov/taxes-forms/withholding-tax/withholding-tax-forms-

and-instructions/withholding-certificate-pension-or-annuity-payments

Oklahoma OK-W-4-P https://oklahoma.gov/content/dam/ok/en/tax/documents/forms/businesses/

general/OK-W-4-P.pdf

Oregon (OR) OR-W-4 https://www.oregon.gov/dor/forms/FormsPubs/form-or-W-4_101-402_2023.pdf

01/24 Page 5 of 5

Form W-4R

Department of the Treasury

Internal Revenue Service

Withholding Certificate for Nonperiodic Payments and

Eligible Rollover Distributions

Give Form W-4R to the payer of your retirement payments.

OMB No. 1545-0074

2024

1a First name and middle initial Last name 1b Social security number

Address

City or town, state, and ZIP code

Your withholding rate is determined by the type of payment you will receive.

• For nonperiodic payments, the default withholding rate is 10%. You can choose to have a different rate by entering a rate between

0% and 100% on line 2. Generally, you can’t choose less than 10% for payments to be delivered outside the United States and its

territories.

• For an eligible rollover distribution, the default withholding rate is 20%. You can choose a rate greater than 20% by entering the rate

on line 2. You may not choose a rate less than 20%.

See page 2 for more information.

2 Complete this line if you would like a rate of withholding that is different from the default withholding

rate. See the instructions on page 2 and the Marginal Rate Tables below for additional information.

Enter the rate as a whole number (no decimals) . . . . . . . . . . . . . . . . . .

Sign

Here

Your signature (This form is not valid unless you sign it.) Date

General Instructions

Section references are to the Internal Revenue Code.

Future developments. For the latest information about any

future developments related to Form W-4R, such as

legislation enacted after it was published, go to

www.irs.gov/FormW4R.

Purpose of form. Complete Form W-4R to have payers

withhold the correct amount of federal income tax from your

nonperiodic payment or eligible rollover distribution from an

employer retirement plan, annuity (including a commercial

annuity), or individual retirement arrangement (IRA). See

page 2 for the rules and options that are available for each

type of payment. Don’t use Form W-4R for periodic

payments (payments made in installments at regular

intervals over a period of more than 1 year) from these plans

or arrangements. Instead, use Form W-4P, Withholding

Certificate for Periodic Pension or Annuity Payments. For

more information on withholding, see Pub. 505, Tax

Withholding and Estimated Tax.

Caution: If you have too little tax withheld, you will generally

owe tax when you file your tax return and may owe a penalty

unless you make timely payments of estimated tax. If too

much tax is withheld, you will generally be due a refund

when you file your tax return. Your withholding choice (or an

election not to have withholding on a nonperiodic payment)

will generally apply to any future payment from the same

plan or IRA. Submit a new Form W-4R if you want to change

your election.

2024 Marginal Rate Tables

You may use these tables to help you select the appropriate withholding rate for this payment or distribution. Add your income

from all sources and use the column that matches your filing status to find the corresponding rate of withholding. See page 2

for more information on how to use this table.

Single

Married filing separately

Married filing jointly

Qualifying surviving spouse

Head of household

Total income

over—

Tax rate for every

dollar more

Total income

over—

Tax rate for every

dollar more

Total income

over—

Tax rate for every

dollar more

$0 0%

14,600 10%

26,200 12%

61,750 22%

115,125 24%

206,550 32%

258,325 35%

623,950 *

37%

$0 0%

29,200 10%

52,400 12%

123,500 22%

230,250 24%

413,100 32%

516,650 35%

760,400 37%

$0 0%

21,900 10%

38,450 12%

85,000 22%

122,400 24%

213,850 32%

265,600 35%

631,250 37%

* If married filing separately, use $380,200 instead for this 37% rate.

For Privacy Act and Paperwork Reduction Act Notice, see page 3.

Cat. No. 75085T

Form

W-4R (2024)

Form W-4R (2024)

Page

General Instructions (continued)

Nonperiodic payments—10% withholding. Your payer

must withhold at a default 10% rate from the taxable amount

of nonperiodic payments unless you enter a different rate on

line 2. Distributions from an IRA that are payable on demand

are treated as nonperiodic payments. Note that the default

rate of withholding may not be appropriate for your tax

situation. You may choose to have no federal income tax

withheld by entering “-0-” on line 2. See the specific

instructions below for more information. Generally, you are

not permitted to elect to have federal income tax withheld at

a rate of less than 10% (including “-0-”) on any payments to

be delivered outside the United States and its territories.

Note: If you don’t give Form W-4R to your payer, you

don’t provide an SSN, or the IRS notifies the payer that you

gave an incorrect SSN, then the payer must withhold 10% of

the payment for federal income tax and can’t honor requests

to have a lower (or no) amount withheld. Generally, for

payments that began before 2024, your current withholding

election (or your default rate) remains in effect unless you

submit a Form W-4R.

Eligible rollover distributions—20% withholding.

Distributions you receive from qualified retirement plans (for

example, 401(k) plans and section 457(b) plans maintained

by a governmental employer) or tax-sheltered annuities that

are eligible to be rolled over to an IRA or qualified plan are

subject to a 20% default rate of withholding on the taxable

amount of the distribution. You can’t choose withholding at a

rate of less than 20% (including “-0-”). Note that the default

rate of withholding may be too low for your tax situation. You

may choose to enter a rate higher than 20% on line 2. Don’t

give Form W-4R to your payer unless you want more than

20% withheld.

Note that the following payments are not eligible rollover

distributions for purposes of these withholding rules:

• Qualifying “hardship” distributions;

• Distributions required by federal law, such as required

minimum distributions;

• Generally, distributions from a pension-linked emergency

savings account;

• Eligible distributions to a domestic abuse victim;

• Qualified disaster recovery distributions;

• Qualified birth or adoption distributions; and

• Emergency personal expense distributions.

See Pub. 505 for details. See also Nonperiodic payments—

10% withholding above.

Payments to nonresident aliens and foreign estates. Do

not use Form W-4R. See Pub. 515, Withholding of Tax on

Nonresident Aliens and Foreign Entities, and Pub. 519, U.S.

Tax Guide for Aliens, for more information.

Tax relief for victims of terrorist attacks. If your disability

payments for injuries incurred as a direct result of a terrorist

attack are not taxable, enter “-0-” on line 2. See Pub. 3920,

Tax Relief for Victims of Terrorist Attacks, for more details.

Specific Instructions

Line 1b

For an estate, enter the estate’s employer identification

number (EIN) in the area reserved for “Social security

number.”

Line 2

More withholding. If you want more than the default rate

withheld from your payment, you may enter a higher rate on

line 2.

Less withholding (nonperiodic payments only). If

permitted, you may enter a lower rate on line 2 (including

“-0-”) if you want less than the 10% default rate withheld

from your payment. If you have already paid, or plan to pay,

your tax on this payment through other withholding or

estimated tax payments, you may want to enter “-0-”.

Suggestion for determining withholding. Consider using

the Marginal Rate Tables on page 1 to help you select the

appropriate withholding rate for this payment or distribution.

The tables are most accurate if the appropriate amount of

tax on all other sources of income, deductions, and credits

has been paid through other withholding or estimated tax

payments. If the appropriate amount of tax on those sources

of income has not been paid through other withholding or

estimated tax payments, you can pay that tax through

withholding on this payment by entering a rate that is greater

than the rate in the Marginal Rate Tables.

The marginal tax rate is the rate of tax on each additional

dollar of income you receive above a particular amount of

income. You can use the table for your filing status as a

guide to find a rate of withholding for amounts above the

total income level in the table.

To determine the appropriate rate of withholding from the

table, do the following. Step 1: Find the rate that

corresponds with your total income not including the

payment. Step 2: Add your total income and the taxable

amount of the payment and find the corresponding rate.

If these two rates are the same, enter that rate on line 2.

(See Example 1 below.)

If the two rates differ, multiply (a) the amount in the lower

rate bracket by the rate for that bracket, and (b) the amount

in the higher rate bracket by the rate for that bracket. Add

these two numbers; this is the expected tax for this

payment. To get the rate to have withheld, divide this

amount by the taxable amount of the payment. Round up to

the next whole number and enter that rate on line 2. (See

Example 2 below.)

If you prefer a simpler approach (but one that may lead to

overwithholding), find the rate that corresponds to your total

income including the payment and enter that rate on line 2.

Examples. Assume the following facts for Examples 1 and 2.

Your filing status is single. You expect the taxable amount of

your payment to be $20,000. Appropriate amounts have

been withheld for all other sources of income and any

deductions or credits.

Example 1. You expect your total income to be $62,000

without the payment. Step 1: Because your total income

without the payment, $62,000, is greater than $61,750 but

less than $115,125, the corresponding rate is 22%. Step 2:

Because your total income with the payment, $82,000, is

greater than $61,750 but less than $115,125, the

corresponding rate is 22%. Because these two rates are the

same, enter “22” on line 2.

Example 2. You expect your total income to be $43,700

without the payment. Step 1: Because your total income

without the payment, $43,700, is greater than $26,200 but

less than $61,750, the corresponding rate is 12%. Step 2:

Because your total income with the payment, $63,700, is

Form W-4R (2024)

Page

greater than $61,750 but less than $115,125, the

corresponding rate is 22%. The two rates differ. $18,050 of

the $20,000 payment is in the lower bracket ($61,750 less

your total income of $43,700 without the payment), and

$1,950 is in the higher bracket ($20,000 less the $18,050 that

is in the lower bracket). Multiply $18,050 by 12% to get

$2,166. Multiply $1,950 by 22% to get $429. The sum of

these two amounts is $2,595. This is the estimated tax on

your payment. This amount corresponds to 13% of the

$20,000 payment ($2,595 divided by $20,000). Enter “13” on

line 2.

Privacy Act and Paperwork Reduction Act Notice. We ask

for the information on this form to carry out the Internal

Revenue laws of the United States. You are required to

provide this information only if you want to (a) request

additional federal income tax withholding from your

nonperiodic payment(s) or eligible rollover distribution(s); (b)

choose not to have federal income tax withheld from your

nonperiodic payment(s), when permitted; or (c) change a

previous Form W-4R (or a previous Form W-4P that you

completed with respect to your nonperiodic payments or

eligible rollover distributions). To do any of the

aforementioned, you are required by sections 3405(e) and

6109 and their regulations to provide the information

requested on this form. Failure to provide this information

may result in inaccurate withholding on your payment(s).

Failure to provide a properly completed form will result in

your payment(s) being subject to the default rate; providing

fraudulent information may subject you to penalties.

Routine uses of this information include giving it to the

Department of Justice for civil and criminal litigation, and to

cities, states, the District of Columbia, and U.S.

commonwealths and territories for use in administering their

tax laws. We may also disclose this information to other

countries under a tax treaty, to federal and state agencies to

enforce federal nontax criminal laws, or to federal law

enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested

on a form that is subject to the Paperwork Reduction Act

unless the form displays a valid OMB control number. Books

or records relating to a form or its instructions must be

retained as long as their contents may become material in

the administration of any Internal Revenue law. Generally,

tax returns and return information are confidential, as

required by section 6103.

The average time and expenses required to complete and

file this form will vary depending on individual

circumstances. For estimated averages, see the instructions

for your income tax return.

If you have suggestions for making this form simpler, we

would be happy to hear from you. See the instructions for

your income tax return.