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Retirement Services State and Federal Withholding Certificate For Pension Payments Name: Address: Phone: Email: Jurisdiction: Social Security Number: COMPLETE SECTION 1 FOR FEDERAL WITHHOLDING AND SECTION 2 FOR STATE WITHHOLDING Section 1 – FEDERAL WITHHOLDING – Please complete only one option A, B or C A) I elect NOT to have federal income tax withheld from my pension payment. B) Please elect your filing status and the number of exemptions below. If no exemptions are provided, the default will be Zero. Single Married Married but withhold at Single Rate Number of Exemptions (Must be numeric value): Plus an Additional Flat Amount of: $ C) I only want a flat dollar amount or % withheld from each payment. or (must be in even multiples of $5.00) Section 2 – STATE TAX WITHHOLDING – Please complete only one option A, B or C A) I elect NOT to have Georgia State income tax withheld from my pension payment. B) Please elect your filing status and the number of exemptions below. If no exemptions are provided, the default will be Zero. Married Filing Joint One Working Married Filing Joint Both Working Married Filing Separate Single Head of Household Number of Exemptions (Must be numeric value): Plus an Additional Flat Amount of: $ C) I only want a flat dollar amount or % withheld from each payment. or (must be in even multiples of $5.00) SIGNATURE DATE Return completed form to: ACCG Retirement Services, Attn: Defined Benefit Department, 12195 Hwy 92 Suite 114-392, Woodstock, GA 30188 Phone (770) 952-5225 or (800) 736-7166 Fax (770) 563-9356 SIGN