"Georgia State Income Tax Substitute Form G-4p" - Georgia (United States)

Georgia State Income Tax Substitute Form G-4p is a legal document that was released by the Employees' Retirement System of Georgia - a government authority operating within Georgia (United States).

Form Details:

  • Released on December 1, 2020;
  • The latest edition currently provided by the Employees' Retirement System of Georgia;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Employees' Retirement System of Georgia.

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E RSGA
*D0$*
Employees’ Retirement
System of Georgia
Serving those who serve Georgia
GEORGIA STATE INCOME TAX Substitute Form G-4P
Withholding Certificate for Pension or Annuity Payment
Please print clearly. Blue ink is preferred. Mail this completed form along with any other required documentation needed to process your request to the
Employees’ Retirement System of Georgia (ERSGA). Funds are deposited on the last work day of each month. Access your account at ers.ga.gov to
update your direct deposit online, review check stubs, and more.
SECTION 1 - Your Information
Note: We will update our records to reflect the mailing address listed below.
Name:
SSN:
-
-
(Last)
(First)
(MI)
(Maiden)
Mailing Address:
(Street)
(City)
(State)
(Zip)
Date of Birth:
/
/
Email:
Phone (
)
□ Cellular
□ Home
□ Work
mm/dd/yyyy
SECTION 2 – Benefit Payments to Update
Select all benefit payments that should be sent to the account listed below.
All payments selected will be updated based on the tax elections listed in Section 3 and 4. If you are receiving multiple benefit payments each month (e.g.,
(a survivor benefit payment (beneficiary) and a retirement benefit payment or retirement benefit payments from two separate plans) and would like the
separate payments to have different tax elections, complete and submit a separate form for each payment or we recommend you update your tax elections
online. If no selection is made, all benefit payments will be updated to the tax election below
Legislative Retirement System (LRS)
□ Retiree □ Beneficiary
Employees’ Retirement System (ERS)
□ Retiree □ Beneficiary
Public Schools Employees Retirement System (PSERS)
1st ERS Supplemental Guaranteed Lifetime Income (SGLI)
□ Retiree □ Beneficiary
□ Retiree □ Beneficiary
Georgia Judicial Retirement System (GJRS)
□ Retiree □ Beneficiary
2nd ERS Supplemental Guaranteed Lifetime Income (SGLI)
□ Retiree □ Beneficiary
Georgia Military Pension Fund (GMPF)
□ Retiree □ Beneficiary
SECTION 3 – Tax Options
Indicate the appropriate tax filing options below.
1.
All retirees age 62 and older and those retirees totally and permanently disabled (as defined by provisions in the Georgia Income Tax regulations) may
be eligible for additional tax exemptions. Contact the Georgia Department of Revenue (DOR) or consult a tax adviser for further information and for any
specific questions regarding the withholding of State income tax.
2.
CAUTION: Having no tax withheld or failure to have enough tax withheld, may result in your being responsible for payment of estimated taxes. Penal-
ties may incur if the tax withheld and estimated tax payments are not sufficient to cover your tax liability. Consult the Georgia DOR or a tax advisor to
determine if the penalties for underpayment apply to you.
FILING STATUS (Choose only one): ______ Single ______ Head of Household ______ Married Filing Separate
________ Married Filing Jointly: One Spouse Working
________ Married Filing Jointly: Both Spouses Working
EXEMPTIONS: I claim ______ total dependents/ exemptions/allowances.
SECTION 4 - Withholding Options
Please refer to the instructions on page 2 of this form, then choose all that apply.
1. Do NOT withhold Georgia State income tax from my monthly benefit. (Do not complete lines 2 or 3.)
2. Withhold from each monthly benefit payment an amount to be figured using the filing status and the number of exemptions I listed
above.
3. Withhold the following additional amount from each monthly benefit payment: $ _________________.
NOTE: Choose only if line 2 is completed.
SECTION 5 - Signature
I understand that by signing this form, I am certifying that the above information is complete and accurate. This information continues in effect until I cancel
or change it in writing or online.
Signature:
Date:
DO 12/2020
Page 1 of 2
Two Northside 75 Suite 300 • Atlanta, GA 30318-7778 • PHONE (404) 350-6300 (800) 805-4609 • FAX (404) 350-6308 • ers.ga.gov
E RSGA
*D0$*
Employees’ Retirement
System of Georgia
Serving those who serve Georgia
GEORGIA STATE INCOME TAX Substitute Form G-4P
Withholding Certificate for Pension or Annuity Payment
Please print clearly. Blue ink is preferred. Mail this completed form along with any other required documentation needed to process your request to the
Employees’ Retirement System of Georgia (ERSGA). Funds are deposited on the last work day of each month. Access your account at ers.ga.gov to
update your direct deposit online, review check stubs, and more.
SECTION 1 - Your Information
Note: We will update our records to reflect the mailing address listed below.
Name:
SSN:
-
-
(Last)
(First)
(MI)
(Maiden)
Mailing Address:
(Street)
(City)
(State)
(Zip)
Date of Birth:
/
/
Email:
Phone (
)
□ Cellular
□ Home
□ Work
mm/dd/yyyy
SECTION 2 – Benefit Payments to Update
Select all benefit payments that should be sent to the account listed below.
All payments selected will be updated based on the tax elections listed in Section 3 and 4. If you are receiving multiple benefit payments each month (e.g.,
(a survivor benefit payment (beneficiary) and a retirement benefit payment or retirement benefit payments from two separate plans) and would like the
separate payments to have different tax elections, complete and submit a separate form for each payment or we recommend you update your tax elections
online. If no selection is made, all benefit payments will be updated to the tax election below
Legislative Retirement System (LRS)
□ Retiree □ Beneficiary
Employees’ Retirement System (ERS)
□ Retiree □ Beneficiary
Public Schools Employees Retirement System (PSERS)
1st ERS Supplemental Guaranteed Lifetime Income (SGLI)
□ Retiree □ Beneficiary
□ Retiree □ Beneficiary
Georgia Judicial Retirement System (GJRS)
□ Retiree □ Beneficiary
2nd ERS Supplemental Guaranteed Lifetime Income (SGLI)
□ Retiree □ Beneficiary
Georgia Military Pension Fund (GMPF)
□ Retiree □ Beneficiary
SECTION 3 – Tax Options
Indicate the appropriate tax filing options below.
1.
All retirees age 62 and older and those retirees totally and permanently disabled (as defined by provisions in the Georgia Income Tax regulations) may
be eligible for additional tax exemptions. Contact the Georgia Department of Revenue (DOR) or consult a tax adviser for further information and for any
specific questions regarding the withholding of State income tax.
2.
CAUTION: Having no tax withheld or failure to have enough tax withheld, may result in your being responsible for payment of estimated taxes. Penal-
ties may incur if the tax withheld and estimated tax payments are not sufficient to cover your tax liability. Consult the Georgia DOR or a tax advisor to
determine if the penalties for underpayment apply to you.
FILING STATUS (Choose only one): ______ Single ______ Head of Household ______ Married Filing Separate
________ Married Filing Jointly: One Spouse Working
________ Married Filing Jointly: Both Spouses Working
EXEMPTIONS: I claim ______ total dependents/ exemptions/allowances.
SECTION 4 - Withholding Options
Please refer to the instructions on page 2 of this form, then choose all that apply.
1. Do NOT withhold Georgia State income tax from my monthly benefit. (Do not complete lines 2 or 3.)
2. Withhold from each monthly benefit payment an amount to be figured using the filing status and the number of exemptions I listed
above.
3. Withhold the following additional amount from each monthly benefit payment: $ _________________.
NOTE: Choose only if line 2 is completed.
SECTION 5 - Signature
I understand that by signing this form, I am certifying that the above information is complete and accurate. This information continues in effect until I cancel
or change it in writing or online.
Signature:
Date:
DO 12/2020
Page 1 of 2
Two Northside 75 Suite 300 • Atlanta, GA 30318-7778 • PHONE (404) 350-6300 (800) 805-4609 • FAX (404) 350-6308 • ers.ga.gov
GEORGIA STATE INCOME TAX
Withholding Certificate for Pension or Annuity Payments
Section 4 Instructions
1. Choose this option if you do not want any tax withheld from your benefit check.
2. Choose this option if you wish to withhold taxes based on Georgia Department of Revenue tax tables using the filing
status and the number of exemptions you listed.
3. Choose this option if you wish to have an additional specific dollar amount withheld. NOTE: Choose only if line 2 is
completed.
Your choice is effective until you notify us in writing on another G-4P. For a change to be effective for a particular month, the
request must be received by the 18th of the month. You may revoke or change this form at any time.
Employees’ Retirement System of Georgia
Two Northside 75 Suite 300
Atlanta, GA 30318-7778
Local (404) 350-6300
Toll Free 1-800-805-4609
ers.ga.gov
DO 12/2020
Page 2 of 2
Two Northside 75 Suite 300 • Atlanta, GA 30318-7778 • PHONE (404) 350-6300 (800) 805-4609 • FAX (404) 350-6308 • ers.ga.gov
Page of 2