Virginia Withholding Exemption Certificate for Recipients of Pension and Annuity Payment

Withholding Exemption Certificate for Recipients of Pension and Annuity Payment
Form VA-4P -  Virginia Withholding Exemption Certificate for Recipients of Pension and Annuity Payments
FORM VA-4P INSTRUCTIONS
VIRGINIA DEPARTMENT OF TAXATION
WITHHOLDING EXEMPTION CERTIFICATE FOR RECIPIENTS OF
PENSION AND ANNUITY PAYMENTS
Use this form to notify your pension
administrator or other payer whether
income tax is to be withheld, and on what
basis.
Am I required to file Form VA-4P? Yes.
You MUST file Form VA-4P with your
pension or annuity payer before your
payments begin. If you do not file Form
VA-4P, your payer is required to withhold
Virginia income tax from your payments as
if you had claimed zero exemptions.
Can I elect “no withholding”?. You may
use this form to elect “no withholding”

if you have made a similar election for
federal purposes, or if you meet any of
the conditions listed in the instructions for
Line 4 of Form VA-4P on the reverse side
of this sheet.

file your estimated payment on our website,
www.tax.virginia.gov. You may also order
Form 760ES by calling (804) 367-8037 or
contacting your local commissioner of the
revenue.

What if I have other income? If you have
income from other sources which is not
subject to Virginia income tax withholding,
you should consider making estimated tax
payments on Form 760ES or requesting
that an additional amount of tax be withheld
from your pension or annuity payment. You
can download Form 760ES or electronically

How do I complete Form VA-4P? Be sure
to read the instructions on the reverse side
of this page carefully before completing
Form VA-4P. If you need assistance, you
may contact the Department of Taxation at
(804) 367-8037.

PERSONAL EXEMPTION WORKSHEET
1. 	 Enter “1” for yourself................................................................................................... 	
2. 	 If you are married and your spouse is not claimed on his or her own certificate,
	
enter “1”....................................................................................................................... 	
3.	 Enter the number of dependents you will claim on your income tax return
	
(do not include your spouse)....................................................................................... 	
4.	 Subtotal of Personal Exemptions – add Lines 1-3....................................................................................... 	 ____________________
5.	 Exemptions for age
	
a)	 If you will be 65 or older on January 1, enter “1”.................................................. 	
	
b) 	 If you claimed an exemption on Line 2 above and your spouse will
		
be 65 or older on January 1, enter “1”................................................................. 	
6.	 Exemptions for blindness
	
a) 	 If you are legally blind enter “1”............................................................................
	
b) 	 If you claimed an exemption on Line 2 above and your spouse is
		
legally blind, enter “1”........................................................................................... 	
7.	 Subtotal of Age and Blindness Exemptions – add Lines 5 & 6.................................................................... 	 ____________________
8. 	 Total exemptions (add Lines 4 and 7) ..................................................................................................... 	 ____________________
--------------------------------------- CUT HERE AND SEND TO THE PAYER OF YOUR PENSION OR ANNUITY-------------------------------------Form VA-4P Virginia Withholding Exemption Certificate for
Recipients of Pension and Annuity Payments
Your Social Security Number
Name
Street Address
City

State

ZIP Code

Complete the applicable lines below:

2601062  Rev. 04/19

1.	 If subject to withholding, enter the number of exemptions claimed on:
	

(a) Subtotal of Personal Exemptions – Line 4 of the Personal Exemption Worksheet................................. 	 ____________________

	

(b) Subtotal of Age and Blindness Exemptions – Line 7 of the Personal Exemption Worksheet................. 	 ____________________

	

(c) Total Exemptions – Line 8 of the Personal Exemption Worksheet.......................................................... 	 ____________________

2.	 Enter the amount of additional withholding requested (see instructions)..................................................... 	 ____________________
3. 	 Enter the amount of voluntary withholding requested (see instructions)...................................................... 	 ____________________
4. 	 I certify that I am not subject to Virginia withholding, either because I have elected “no withholding”
	
for federal purposes, or I meet the conditions for exemption set forth in the instructions
	
for Form VA-4P. .................................................................................................................... (Check here.)		 j
	
Signature________________________________________________________________________ 	Date ________________________________

FORM VA-4P
LINE BY LINE INSTRUCTIONS
PERSONAL EXEMPTION WORKSHEET
In order to compute the proper amount of Virginia income tax withheld, your payer must know the number of personal
exemptions you are entitled to claim. The Personal Exemption Worksheet is designed to allow you to review all of the possible
exemptions so that you can choose the appropriate number to report to your payer.
You may not claim more exemptions on Form VA-4P than you are entitled to claim on your income tax return, unless you
have received written permission to do so from the Department of Taxation.
Line 1.	 You may claim an exemption for yourself.
Line 2.	 You may claim an exemption for your spouse if he or she is not already claimed on his or her own certificate.
Line 3. 	Enter the number of dependents you are allowed to claim on your income tax return.
	

NOTE: A spouse is not a dependent.

Line 5.	 If you will be age 65 or over by January 1, you may claim one exemption on Line 5(a). If you claim an exemption
for your spouse on Line 2, and your spouse will also be age 65 or over by January 1, you may claim an additional
exemption on Line 5(b).
Line 6.	 If you are legally blind, you may claim an exemption on Line 6(a). If you claimed an exemption for your spouse on
Line 2, and your spouse is legally blind, you may claim an exemption on Line 6(b).

Retain this worksheet for your records.

FORM VA-4P
Be sure to enter your name, address, and Social Security number in the spaces provided. Your payer must have this information
to properly identify your withholding liability.
Line 1.	 If you are subject to withholding, enter the number of exemptions from:
	

(a)	

Subtotal of Personal Exemptions – Line 4 of the Personal Exemption Worksheet

	

(b) 	

Subtotal of Exemptions for Age and Blindness – Line 7 of the Personal Exemption Worksheet

	

(c)	

Total Exemptions – Line 8 of the Personal Exemption Worksheet

Line 2.	 If you wish to have an additional amount withheld from your payment, enter the amount on Line 2.
Line 3.	 If you elected “no withholding” for federal purposes, but wish to have Virginia income tax withheld, enter the amount
you want withheld from each payment on Line 3.
Line 4.	 If you are not subject to Virginia withholding, check the box on Line 4. You are not subject to Virginia withholding if
you meet any of the following conditions:
	

(a)	

You elected “no withholding” for federal purposes; or

	

(b)	

You are not a resident of Virginia; or

	

(c)	

You incurred no income tax liability for last year and do not expect to incur a liability for this year; or

	

(d)	

You expect your Virginia adjusted gross income to be less than the amount shown below for your filing 		
status:
Taxable Years Taxable Years Taxable Years Taxable Years
2005, 2006
2008 and
2010 and
2012 and
and 2007
2009
2011
Beyond
Single

$7,000

$11,250

$11,650

$11,950

Married

$14,000

$22,500

$23,300

$23,900

Married, filing a separate
return

$7,000

$11,250

$11,650

$11,950

Sign Form VA-4P, cut at the line indicated, and file the completed form with your payer.