New York Annuitant's Request for Income Tax Withholding

Annuitant's Request for Income Tax Withholding
Form IT-2104-P:8/15:Annuitant's Request for Income Tax Withholding:it2104p
Department of Taxation and Finance

Annuitant’s Request for Income Tax Withholding

IT-2104-P
(8/15)

New York State  •  New York City  •  Yonkers
Print or type

	 First name and middle initial	

Last name				

	 Permanent mailing address (number and street or PO box)			
		
	
	

Apartment number	
	
	

	 City, village, or post office	

ZIP code

	

State	

Your social security number

Annuity contract claim or
identification number

	1	 New York State income tax ................................................................... 	  1
	 2	 New York City income tax (if a New York City resident).............................. 	  2
	 3	 Yonkers income tax surcharge (if a Yonkers resident)............................... 	  3

Enter the whole dollar
amount to be withheld
from each annuity or
pension payment:

	I request voluntary income tax withholding from my annuity or pension payments as authorized by section 671(b) of the Tax Law.
	 Signature of annuitant	

IT-2104-P (8/15) (back)

Date

	

Instructions

Payee
Who may file
If you receive an annuity or pension payment that must be included in your
New York adjusted gross income, you may file this form to have New York
State income tax (and, if a New York City or Yonkers resident, that city’s
personal income tax) withheld from each payment. However, the annuity or
pension must be payable over a period longer than one year.

Statement of income tax withheld
After the end of the year, your payer will give you federal Form 1099‑R,
Distributions From Pensions, Annuities, Retirement or Profit‑Sharing Plans,
IRAs, Insurance Contracts, etc., showing the gross amount of annuity or
pension payments and the total amount deducted and withheld as tax during
the calendar year.

Payer

Where and how to file
File this form with the payer of your annuity or pension. Enter on the front the
whole dollar amount(s) that you want withheld from each annuity or pension
payment. However, each amount must be at least $5 per month and should
not reduce the annuity or pension payment you receive to less than $10.
Quarterly payments of estimated income tax may be made in addition to or
instead of withholding; see Form IT‑2105‑I, Instructions for Form IT‑2105, for
more information.

Keep this certificate with your records.

If you need help completing this form, call (518) 457-5181.

See our Web site or Publication 54, Privacy Notification.

See the instructions for Form NYS‑1, Return of Tax Withheld, and
Form NYS‑45, Quarterly Combined Withholding, Wage Reporting, and
Unemployment Insurance Return, for payment and reporting requirements for
New York State, New York City, and Yonkers personal income taxes that you
withheld from annuity or pension payments.

Privacy notification

Duration of withholding request
Your request for voluntary withholding will remain in effect until you terminate it.
How to terminate a withholding request
You may terminate your request for voluntary withholding by giving your payer
a written termination notice.

www.tax.ny.gov