State Form 37365 (WH-4P) "Annuitant's Request for State and County Income Tax Withholding" - Indiana

What Is State Form 37365 (WH-4P)?

This is a legal form that was released by the Indiana Department of Revenue - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2008;
  • The latest edition provided by the Indiana Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of State Form 37365 (WH-4P) by clicking the link below or browse more documents and templates provided by the Indiana Department of Revenue.

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Download State Form 37365 (WH-4P) "Annuitant's Request for State and County Income Tax Withholding" - Indiana

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Form WH-4P
State of Indiana
Annuitant’s Request
State Form 37365
(R2 / 8-08)
for State and County Income Tax Withholding
(Please Type or Print Clearly)
Full Name _________________________________________________________________________
Social Security Number
Home Address (number and street) _____________________________________________________
City, State, and Zip code ______________________________________________________________
A.
Annuity contract claim or identification number ................................................................................................... A.
_______________
B.
Enter the amount of Indiana state tax to be withheld from each annuity or pension payment ............................ B. $ _______________
C.
Enter your 2-digit county code
and the amount of county tax to be withheld from each annuity or
pension payment ................................................................................................................................................. C. $ _______________
D.
Total amount withheld: add line B plus line C (must be $10 or more) ................................................................. D. $ _______________
I request voluntary income tax withholding from my annuity or pension payments.
_________________________________________________________
____________________________
Signature of Annuitant
Date
Form WH-4P
State of Indiana
Annuitant’s Request
State Form 37365
(R2 / 8-08)
for State and County Income Tax Withholding
(Please Type or Print Clearly)
Full Name _________________________________________________________________________
Social Security Number
Home Address (number and street) _____________________________________________________
City, State, and Zip code ______________________________________________________________
A.
Annuity contract claim or identification number ................................................................................................... A.
_______________
B.
Enter the amount of Indiana state tax to be withheld from each annuity or pension payment ............................ B. $ _______________
C.
Enter your 2-digit county code
and the amount of county tax to be withheld from each annuity or
pension payment ................................................................................................................................................. C. $ _______________
D.
Total amount withheld: add line B plus line C (must be $10 or more) ................................................................. D. $ _______________
I request voluntary income tax withholding from my annuity or pension payments.
_________________________________________________________
____________________________
Signature of Annuitant
Date
You may select any amount over $10.00 to be withheld from your annuity or pension payment. This withholding will be
reported to you on a W-2P at the end of each year as Indiana State and County Tax Withheld. Beginning January 1, 2009
an annuitant can request the payor of an annuity or pension to withhold a portion of their pension or annuity to offset their
county tax liability under IC 6-3.5.
A.
Enter the Contract, Policy, or Account Number to which the request applies.
B.
Enter an amount of state tax that you wish to have withheld from each check.
C.
Enter your 2-digit county code and the amount of county tax to be withheld from each annuity or pension payment
D.
Total amount withheld: add line B plus line C (must be $10 or more)
Send this form to the person or company paying your pension. Do not send this to the Department of Revenue.
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