Retirement Forms - PSPRS - by liwenting

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 nstructions:
                                CORRECTIONS OFFICER RETIREMENT PLAN
                                    Normal Retirement - Input Sheet
When inputting information, input dates in the mm/dd/yy format. Other than the dates, input all numbers with no breaks
or special characters (i.e., dashes or parentheses), the computer will format as necessary. Only input in the white
spaces.                                                                      This member is a Dispatcher
                                                                       PLEASE SELECT BENEFIT TYPE:
TODAY'S DATE:
                                                                          NORMAL RETIREMENT
RETIRE DATE:
Not Applicable                                                            ACCIDENTAL DISABILITY
PERSONAL INFORMATION                                                      TOTAL AND PERMANENT DISABILITY

First Name                                                                ORDINARY DISABILITY

Middle Name                                                               SURVIVING SPOUSE         GUARDIAN
Last Name                                                                                           Member was retired

Social Security No.                                                                                 Killed in the line of duty

Sex                                                                       DESIGNATED BENEFICIARY
Member Date of Birth                                                      REPRESENTATIVE OF DECEDENT'S ESTATE

Marital Status                Single   Married                            DEFERRED ANNUITY

SPOUSE INFORMATION
First Name                                       Date of Birth
Middle Name                                      Social Security No.
Last Name                                        Date of Marriage

CONTACT INFORMATION OF MEMBER
                  Address 1                                       Address 2

          City           State                           Zip
                          AZ
 Home Phone Number Work Phone Number             Cell Phone Number

                  Email

DEPENDENT CHILDREN
Child #1 Name
Date of Birth
Disabled?
Child #2 Name
Date of Birth
Disabled?
Child #3 Name
Date of Birth
Disabled?
Child #4 Name
Date of Birth
Disabled?
Child #5 Name
Date of Birth
Disabled?

RETIREE EMPLOYMENT INFORMATION
Current Employer                                                               Not Applicable
    Service      From:
    Service        To:
Local Board Name
Compensation                                                                                          Not Applicable
List total compensation for the highest three consecutive years within the last twenty
completed years of credited service.
           Year                       Through                       Amount                       Final Contribution made to CORP
                                                                                                           Amount
                                                                                                Pay Period Ending
                                                                                          Prior/Combined Salary per
                                                                                                 joinder agreement:
                                                                                            Salary from other CORP
                                                                                                          employer:

Leaves without Pay (LWOP)
During my period(s) of covered service, I have been on leave of absence without pay for
the number of entire pay periods as indicated below:
                                                                                                   Age of Member: 0
                                                                                NONE
  Missing Pay Periods         Employer




Prior Service
        From                          Through             Employer                                         NONE
Flat number (years) >>




Industrial Leave
During my period(s) of covered service, I have received compensation benefits under the Worker's Compensation
Laws of the State of Arizona as indicated below:
                                                                                                    NONE
           From                       Through             Employer




PAYMENT INFORMATION
Payable to
Payment Method

DIRECT DEPOSIT INFORMATION
Financial Institution
Phone Number
MEMBER'S ACCOUNT INFORMATION                                    Select
Bank ABA Routing #                                               forms
Account Type                                                   to Print:          C4          C8     C11     C12       W-4P   A-4P
Bank Account No.                                                           Normal Retirement: Forms C4, C8, C11, C12
BENEFICIARY INFORMATION (only for Normal, Disability or Survivor Applicants)
Primary Beneficiary(ies)                                                                           Relationship(s)
Date(s) of Birth
Contingent Beneficiary(ies)                                                                        Relationship(s)
Date(s) of Birth
                         Forms Prepared By:
                             Phone Number:
                      SYS
                        ID
                     NAME
                     PLAN 5
           BENEFIT AMOUNT 0.00
                 YRS SERV
               LAW AMEND 38-881/ 06 AMEND
             DATE RETIRED
              STATE TAX %
                TERM DATE

                      SYS
                        ID
                     NAME
                      SSN    0
                 ADDRESS
                   ADDR 2
                      CITY
                    STATE    AZ
                       ZIP
                 COUNTRY
                   PHONE
                      SEX
                MEMB DOB     1/0/1900
                  MARITAL
              EXEMPTIONS
                 BENTYPE     01
             PERCENT REC     100
                  CHK SAV    00
             ACT INACTIVE    Y
             B TERM CODE     0
     TOTAL CONTRIBUTIONS     0
NONTAXABLE CONTRIBUTIONS     0
                     DROP    0
 For CORP Use Only                     CORRECTIONS OFFICER RETIREMENT PLAN                                             FORM C4
System:                           3010 East Camelback Road Suite 200, Phoenix, Arizona 85016                              09/09
I.D. :                           PHONE: (602)255-5575 FAX: (602)296-2369 www.psprs.com
Date
Retired:                                APPLICATION FOR NORMAL RETIREMENT


TO:                                                                                  DATE:

       I,                                                        , hereby submit my application for retirement under the terms
of the Arizona Corrections Officer Retirement Plan. I meet the minimum eligibility requirements for a normal retirement; at the
time of termination; namely, (1) 20 or more years of service, (2) age 62 with 10 or more years of service, (3) a dispatcher with 25
years of service, or (4) the sum of my age and years of credited service equals at least eighty (A.R.S. Section 38-885.B).
           I am retiring on                   , acknowleging that the effective date of my retirement will be the first day of the
month following the date of retirement, with payments beginning on or about the last day of the month (A.R.S. Section 38-890). If
application is being made under a prior law, please state prior system law: _________________________________.



    Address:                                                       Home Phone Number:
                                    , AZ                            Work Phone Number:
       Email:                                                         Cell Phone Number:


                                                            SPOUSE

Name:                                          Date of Birth:                         Date of Marriage:
   Social Security Number:


                                                   DEPENDENT CHILDREN
                                                                                                             Is Child 18-22 and
NAME                                          DATE OF BIRTH                  DISABLED?                      in school fulltime?




NOTE: Please provide a copy of:
                1.   Your Birth Certificate
                2.   Your Marriage Certificate
                3.   Your Spouse's Birth Certificate
                4.   Your Dependent Childrens' Birth Certificates
                5.   Copy of Divorce Decree (no split with ex-spouse)
                6.   Certified Copy of Plan Approved Domestic Relations Order
                7.   Medical Documentation For Disabled Children. (If applicable)
                8.   Proof of Fulltime School Enrollment (If applicable)


                                                                                          (NOTE: Please complete 2nd page)
                                 APPLICATION FOR NORMAL RETIREMENT                                           FORM C4
                                                                                                            Page 2 of 2

Name:                                                Soc. Sec. Num.:                       Date:
   Date Of Birth:
1. LEAVE(S) WITHOUT PAY: During my period(s) of covered service, I have been on leave of absence without
pay as indicated below:

          (a) None
                            Missing Pay Periods    Employer
          (b)        1.
                     2.
                     3.
                     4.
                     5.

2. INDUSTRIAL LEAVE: During my period(s) of covered service, I have received compensation benefits under
the Worker's Compensation Laws of the State of Arizona as indicated below:

          (a) None
                             From      Through     Employer
          (b)        1.
                     2.
                     3.
                     4.

3. The information contained above is true, complete and correct to the best of my knowledge and belief.
Further, I HEREBY AUTHORIZE the Local Board, the office of the Fund Manager and/or their authorized
designee to procure from my employer(s) or from any other person, firm or corporation (including any
governmental agency or department thereof) any and all information as directly related to leave(s) of absence
without pay and/or application(s) for and/or receipt of Worker's Compensation Benefits. I expressly waive all
provision of law forbidding any doctor, person, firm or corporation (including any governmental agency or
department thereof) from disclosing any knowledge or information which they have in their possession
concerning leave(s) of absence without pay and/or Worker's Compensation.

This is a limited release and is only to be in effect from this date to 120 days after first receipt of my retirement
benefits.



                      Witness                                                        Member's Signature

Date:


                                EMPLOYER'S CERTIFICATION OF RETIREMENT DATE:

          The above-named member's employment will terminate on


   By:                                                                           Dated:
                          Employer's Authorized Signatory
 Title:                                                                        Witness:
  FOR CORP USE ONLY                     CORRECTIONS OFFICER RETIREMENT PLAN                                          FORM C8
SYS:                              3010 East Camelback Road Suite 200, Phoenix, Arizona 85016                            09/09
ID:                              PHONE: (602)255-5575 FAX: (602)296-2369 www.psprs.com
                                            CHANGE OF BENEFICIARY DESIGNATION


I,                              , the undersigned, in the event of my death, and after any survivor pension
payable from the system has terminated, direct that if there remain any of my accumulated contributions arising
from deductions made from my salaries in excess of pension payments paid to me or to a survivor, those remaining
contributions
be paid to:                                                                                                    ,
                                     Name(s) of primary refund beneficiary(ies) / Trust
whose relationship(s) to me is (are):                                                                                       ,

social security number(s):                                                                                                  ,

and whose date(s) of birth (are):                                                                                           ,

if living, otherwise to:                                                                                                    ,
                                                     Name(s) of contingent refund beneficiary(ies) / Trust
whose relationship(s) to me is (are):                                                                                       ,

social security number(s):                                                                                                  ,

and whose date(s) of birth (are):                                                                                           .


if living, otherwise to my next-of-kin as determined by the Local Retirement Board. It is agreed that if more than one
primary or contingent beneficiary, as the case may be, is named, my said accumulated contributions, if payable, will
be paid in equal shares to the survivors.


DATED IN                                                     , ON THIS               DAY OF
                           (City or Town), (State)


               WITNESS SIGNATURE                                                        MEMBER SIGNATURE

(Witness must be other than beneficiaries named above)
                                                                                          STREET ADDRESS
Please complete and attach Form C9 if change of
beneficiary reflects a marital status change which                                                             AZ
involves a name change of member                                                       CITY                  STATE    ZIP


                  PHONE NUMBER                                                      SOCIAL SECURITY NUMBER


                                                                                              EMPLOYER
TO THE EMPLOYER: Please forward to CORP
and retain a copy for your records
   For CORP Use Only                    CORRECTIONS OFFICER RETIREMENT PLAN                                         FORM C11
SYSTEM:                           3010 East Camelback Road Suite 200, Phoenix, Arizona 85016                            09/09
I.D. :                           PHONE: (602)255-5575 FAX: (602)296-2369 www.psprs.com
                                                     BENEFIT CALCULATIONS
                                                       A.R.S. Section 38-885

  USE THIS FORM FOR NORMAL SERVICE RETIREMENTS AND DISABILITY, SURVIVING SPOUSE AND GUARDIAN BENEFITS


   MEMBER'S NAME:                                                                         DATE OF BIRTH:
CURRENT EMPLOYER:                                                                         SOC. SEC. NUM.:

YEARS OF SERVICE WITH CURRENT EMPLOYER:
PLUS PRIOR YEARS OF SERVICE:
LESS LEAVES WITHOUT PAY (YEARS):                              (0.000)
LENGTH OF CREDITED SERVICE:                                    0.000     Years

           Amount of last contribution made to CORP:
                               For Pay Period Ending:

A. COMPENSATION: BASE SALARY paid to member during a period of 36 consecutive months of credited service in which
member received highest base salary within the last 120 months of service:




B. TOTAL AMOUNT of highest 36 consecutive months of base salary:………………………………………………………………..
                                                                                    $0.00

C. AVERAGE MONTHLY SALARY (Line B / 36 months):………………………………………..……….                                                   $0.00

D. For retirement with 20 years of credited service but less than 25 years of credited service (Not
available to dispatchers) and (if applicable) 80 point rule if membership date is on/after 8/9/01:
   1. Line C x 50% …………………………………………………………………………………………………………….                 $       -
   2. PLUS 2% of Line C for each year of credited service over 20 years ………………………………. -
                                                                              $
   3. TOTAL MONTHLY BENEFIT ……………………………………………………………………………………………………….                    $ -

E. For Retirement with 25 or more years of credited service and (if applicable) 80 point rule if
membership date is on/after 8/9/01:
   1. Line C x 50% …………………………………………………………………………………………………………….                    $ -
   2. PLUS 2.5% of Line C for each year of credited service over 20 years (12 yr
   max) …………………………………………………………………………                                             $ -
   3. TOTAL MONTHLY BENEFIT ……………………………………………………………………………………………………….                 $ -

F. For retirement with less than 20 years of credited service and (if applicable) 80 point rule if
membership date is on/after 8/9/01:
   Line C x years of credited service (include fractional years) x 2.5% ………………………………………..                       $        -

G. For retirement with 80 point rule and membership date is PRIOR to 8/9/01:
   Line C x years of credited service (include frational years) x 2.5% (MAXIMUM 75% Line C)…………….               $        -

H. For retirement at age 62 with 10 years service but less than 20 years of credited service:
   Line C x years of credited service (include frational years) x 2.5%…………………………………………..                        $        -

I. Surviving Spouse or Guardian Benefit:
   4/5 of Line D3, E3, F, G, or H, whichever is applicable; or if member is not retired at date of death, 40%
   of Line C; except 100% of Line C if member killed in the line of duty…………………………………                           $        -

Calculated by:                                                   Date:                               Phone:
  For CORP Use Only                    CORRECTIONS OFFICER RETIREMENT PLAN                                                FORM C12
SYSTEM:                          3010 East Camelback Road Suite 200, Phoenix, Arizona 85016                                   09/09
I.D. :                          PHONE: (602)255-5575 FAX: (602)296-2369 www.psprs.com
BENEFIT
TYPE:
DATE
RETIRED:                               NOTIFICATION OF BENEFITS AND ELECTION

MEMBER'S NAME:

PAYABLE TO:

TYPE OF BENEFIT:                                                 DATE FIRST PAYMENT DUE:

  1) BENEFITS UNDER ARIZONA CORRECTIONS OFFICER RETIREMENT PLAN
      a) Monthly pension payable to member (A.R.S. Section 38-885 or Section 38-886)                              $             -

      b) Monthly pension payable to surviving spouse or guardian:
         If applicant is a member, the spouse's benefit shown here will be payable upon
         death of the retired member. The spouse's benefit ceases upon death; the
         guardian's/child's benefit ceases when child reaches age 18: (A.R.S. 38-887 or
         38-888 or 38-904)                                                                                        $             -

  2) BENEFITS FROM PRIOR LAW:

      The applicant may elect to receive the following benefits because of membership under a prior
      law in lieu of the above:

     ***************************************************************************
The Local Retirement Board has determined that the applicant above is eligible for the benefit payments as shown above.




                    Name of Local Board                                              Signature of Board Chairman or Secretary


     ***************************************************************************
                     ELECTION AND ACCEPTANCE BY MEMBER OR SURVIVOR
                                  (Initial appropriate line below)

           I ELECT TO ACCEPT the type of pension benefit reflected above as well as the amount of benefits as
           determined under ITEM 1 above, representing the benefits payable to me and to my survivors under the Arizona
           Corrections Officer Retirement Plan.

           I ELECT TO RECEIVE the benefits under ITEM 2 in accordance with the prior law designated as:


I UNDERSTAND that this election to receive benefits pursuant to this document and under the CORP or another system
may not be revoked and is binding upon me or any beneficiary or survivor unless otherwise provided by law.




                    Witness                                                 Signature of Member, Survivor or Guardian



                                                                            Dated:
    Signature of Spouse (If Item 2 has been selected)
                                                 Withholding Certificate for
Form   W-4P                                     Pension or Annuity Payments                                                            2010
    SUBSTITUTE
                                                     States or its possessions) or (b) an                Sign this form. Form W-4P is not valid
Purpose. This form is for recipients of
                                                     additional amount of tax withheld.                  unless you sign it.
pensions, annuities, and certain other
deferred compensation to tell payers                                                                     Other income. If you have a large amount
whether income tax is to be withheld and on          What do I need to do? Complete lines A
                                                     through F of the Personal Allowances                of income from other sources not subject to
what basis. Your options depend on                                                                       withholding (such as interest, dividends, or
whether the payment is periodic,                     Worksheet. Use the additional
                                                     worksheets onpage 2 to adjust your                  taxable social security), consider making
nonperiodic, or an eligible rollover                                                                     estimated tax payments using Form 1040-
distribution as explained on page 3.                 withholding allowances for itemized
                                                     deductions, adjustments to income, or               ES, Estimated Tax for Individuals. Call
  You also may use this form to choose to            multiple pensions/more than one income              1-800-TAX-FORM (1-800-829-3676) for
have (a) no income tax withheld from the             situations. If you do not want income tax           Form 1040-ES, and Pub. 505, Tax
payment (except for eligible rollover                to be withheld, you can skip the                    Withholding and Estimated Tax.
distributions or payments to U.S. citizens           worksheets and go directly to the form at
delivered outside the United                         the bottom of this page.
                                                       Personal Allowances Worksheet
A    Enter "1" for yourself if no one else can claim you as a dependent                                                                A
                      ● You are single and have only one pension; or
                      ● You are married, have only one pension, and your
B     Enter "1" if:    spouse has no income subject to withholding; or                                                                 B
                      ● Your income from a second pension or a job, or your spouse's
                       pension or wages (or the total of all) is $1,500 or less.
C   Enter "1" for your spouse. But you may choose to enter -0- if you are married and have either a spouse who has
    income subject to withhholding, or you have more than one source of income subject to withholding. (Entering
    -0- may help you avoid having too little tax withheld.)                                                                            C
D   Enter number of dependents (other than your spouse or yourself) you will claim on your tax return                                  D
E   Enter "1" if you will file as head of household on your tax return                                                                 E
F   Child Tax Credit (including additional child tax credit)
    ● If your total income will be less than $58,000 ($86,000 if married), enter "2" for each eligible child.
    ● If your total income will be between $58,000 and $84,000 ($86,000 and $119,000 if married), enter "1" for
      each eligible child plus "1" additional if you have 4 or more eligible children                                                  F
G   Add lines A through F and enter total here. Note: This may be different from the number of exemptions you claim
    on your tax return.)                                                                                                               G
                      Cut here and give the certificate to the payer of your pension or annuity. Keep the top part for your records.



       W-4P                                      Withholding Certificate for
Form
    SUBSTITUTE                                  Pension or Annuity Payments                                                            2010
Type or print your full name                                                                                      Your social security number


Home address (number and street or rural route)                                                                   Claim or identification number (if
                                                                                                                  any) of your penion or annuity
City or town, state, and ZIP code
                                                                                                                  contract


Complete the following applicable lines:
 1 Check here if you do not want any Federal income tax withheld from your pension or annuity. (Do not complete lines 2 or 3.)
 2 Total number of allowances and marital status you are claiming for withholding from each periodic pension or
   annuity payment. (You may also designate an additional dollar amount on line 3.) . . . . . . . . . . . . . . .
                                                                                                                                           (Enter number of
   Marital status:       Single         Married         Married, but withhold at higher Single rate                                        allowances.)
 3 Additional amount, if any, you want withheld from each pension or annuity payment. (Note: For periodic payments,
   you cannot enter an amount here without entering the number (including zero) of allowances on line 2.) . . . . . .

Your signature                                                                                           Date
 ARIZONA FORM                                            Annuitant's Request for
       A-4P                                     Voluntary Arizona Income Tax Withholding                                                        2010
              NOTE: This form is effective for annuity or pension payments after December 31, 2009 through June 30, 2010. A new form will be
              available on the Department's website (www.azdor.gov) in late spring 2010. You must make a new election for payments after June
              30, 2010

     SUBSTITUTE
Type or print your full name (last, first, middle initial)                                           Your Social Security Number


Home address (number and street or rural route)                                                      Annuity Contract Claim or I.D. Number


City or town, state, and ZIP code                                                                    Telephone Number




                                            Annuitant's Voluntary Arizona Income Tax Withholding Options
Choose only one*:
1.          I hereby elect to have Arizona income taxes withheld from my annuity or pension payments as authorized by ARS § 43-404.
            I choose to have Arizona withholding at the rate of
         (Check only one box):                 10.7%         20.3%      24.5%          26.7%         33.1%          39.5%     of the federal tax withheld.


2.          I hereby elect to terminate my prior election for voluntary Arizona income tax withholding from my annuity or pension payments as authorized by
            ARS § 43-404.


*ARIZONA WITHHOLDING MUST BE AT LEAST $5 PER MONTH (OR A PROPORTIONATE RATE FOR ANY SHORTER PAY PERIOD).


I certify that I have made the percentage election marked above.

SIGNATURE                                                                                                       DATE




                                                             GENERAL INSTRUCTIONS
Who May Use Form A-4P                                                              Where to Send Form A-4P
A person who receives an annuity or pension may use this form to                   Send Form A-4P to the payor of your annuity or pension. Do not
elect voluntary Arizona income tax withholding. Arizona                            send Form A-4P to the Arizona Department of Revenue.
withholding is a percentage of the amount of federal income tax
withheld from the pension or annuity payment. Therefore, you
may elect voluntary Arizona income tax withholding at the                          Duration of Voluntary Arizona Withholding Election
applicable percentage rates only if you have federal income tax                    The payor of your pension or annuity will withhold Arizona income tax
withheld from the pension or annuity payment. However, if you                      from your payments until you notify the payor to terminate Arizona
elect voluntary Arizona income tax withholding, the minimum                        withholding.
amount is $5 per month (or a proportionate rate for any shorter pay
period).                                                                           How to Terminate a Voluntary Arizona Withholding Election
                                                                                   You may terminate your voluntary Arizona withholding election at any
"Annuity" means any amount paid to an individual as a pension or                   time. You may use the Form A-4P to terminate Arizona withholding
annuity, but only to the extent that the amount is includible in the               or you may send a written notice to the payor of your pension or
Arizona gross income of that individual. "An amount paid as a                      annuity requesting termination of withholding.
pension or annuity" is an amount received as an annuity under the
provisions of the Internal Revenue Code.                                           Statement of Income Tax Withheld
                                                                                   The payor of your pension or annuity will provide you with a form that
You may NOT elect to have Arizona income tax withheld from                         lists the total amount of your pension or annuity payments and the
nonperiodic payments, lump sum distributions, or individual                        total amount of Arizona income tax withheld from these payments for
retirement account distributions, that do not meet the definition of               the current calendar year. The payor of your pension or annuity will
annuity listed above.                                                              provide this form to you early next year.




       ADOR 06-0042 (98)
 ARIZONA FORM                                     Annuitant's Request for
       A-4P                              Voluntary Arizona Income Tax Withholding                                                            2010
     SUBSTITUTE

                               NOTE: This form is effective for annuity or pension payments after June 30th 2010.


Type or print your full name (last, first, middle initial)                                    Your Social Security Number


Home address (number and street or rural route)                                               Annuity Contract Claim or I.D. Number


City or town, state, and ZIP code                                                             Telephone Number




                                          Annuitant's Voluntary Arizona Income Tax Withholding Options
Choose only one*:
1.          I hereby elect to have Arizona income taxes withheld from my annuity or pension payments as authorized by ARS §43-404.
           I choose to have Arizona withholding at the rate of
         (Check only one box):           1.3%          1.8%          2.7%         3.6%        4.2%         5.1%     of the taxable amount of distribution.

              Additional amount to be withheld per distribution $


2.          I hereby elect to terminate my prior election for voluntary Arizona income tax withholding from my annuity or pension payments as authorized
            by ARS §43-404.


I certify that I have made the percentage election marked above.



SIGNATURE                                                                                              DATE



                                                             GENERAL INSTRUCTIONS
Who May Use Form A-4P                                                         Where to Send Form A-4P
A person who receives an annuity or pension may use this                      Send Form A-4P to the payor of your annuity or pension. Do not send
form to elect voluntary Arizona income tax withholding.                       Form A-4P to the Arizona Department of Revenue.
Arizona withholding is a percentage of the amount of the
taxable amount of distribution in Box 2a of federal Form1099-
R. Therefore, you may elect voluntary Arizona income tax                      Duration of Voluntary Arizona Withholding Election
withholding at the applicable percentage rates and designate                  The payor of your pension or annuity will withhold Arizona income tax
an additional amount to be withheld.                                          from your payments until you notify the payor to terminate Arizona
                                                                              withholding.

"Annuity" means any amount paid to an individual as a
pension or annuity, but only to the extent that the amount is                 How to Terminate a Voluntary Arizona Withholding Election
includible in the Arizona gross income of that individual. "An                You may terminate your voluntary Arizona withholding election at any
amount paid as a pension or annuity" is an amount received                    time. You may use the Form A-4P to terminate Arizona withholding or
as an annuity under the provisions of the Internal Revenue                    you may send a written notice to the payor of your pension or annuity
Code.                                                                         requesting termination of withholding.

                                                                              Statement of Income Tax Withheld
You may NOT elect to have Arizona income tax withheld from                    The payor of your pension or annuity will provide you with a form that
nonperiodic payments, lump sum distributions, or individual                   lists the total amount of your pension or annuity payments and the total
retirement account distributions, that do not meet the                        amount of Arizona income tax withheld from these payments for the
definition of annuity listed above.                                           current calendar year. The payor of your pension or annuity will
                                                                              provide this form to you early next year.

You also may NOT elect to have Arizona income tax withheld
from Social Security pensions, Veteran's Administration
annuities, or Railroad Retirement pensions.



       ADOR 91-0042 (03)

								
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