VIRGINIA WITHHOLDING ELECTION FORM ARLINGTON COUNTY VIRGINIA EMP L OYEE by barto

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									                        VIRGINIA WITHHOLDING ELECTION FORM
                                ARLINGTON COUNTY, VIRGINIA
                               EMP L OYEE S’ RE T IREM E NT SYS T EM
                                                    SUITE 511
                                        2100 CLARENDON BOULEVARD
                                         ARLINGTON, VIRGINIA 22201
                                          TELEPHONES: (703) 228-3900
                                       (800) 296-9510 FAX (703) 228-3902




1. NAME   (LAST)             (FIRST)            (MIDDLE)         2. SOCIAL SECURITY NUMBER



3. STREET ADDRESS



4. CITY                         5. STATE                         6. ZIP CODE




  7. TOTAL NUMBER OF EXEMPTIONS



  8. ADDITIONAL AMOUNT, IF ANY, YOU WANT DEDUCTED FROM EACH CHECK.



  9. ENTER THE AMOUNT OF VOLUNTARY WITHHOLDING PER MONTH
     (If you want to specify a monthly withholding amount, please complete number 9 only.)



  10. I CERTIFY THAT I AM NOT SUBJECT TO VIRGINIA WITHHOLDING AND
      ELECT TO HAVE NO VIRGINIA STATE TAX WITHHELD FROM MY PENSION.




                    SIGNATURE                                                            DATE




                                                                                                Revised 05/2005

								
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