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                     Missouri Department of Revenue
               Form  Withholding Certificate for  
  MO W-4P            Pension or Annuity Statements 

 This form is to be provided to the administrator of your retirement plan.  Do not send to the Department of Revenue.  
  
 This certificate is for voluntary withholding of Missouri State Income Tax from pension or annuity income only.

  Full Name (Typed or Printed)                                                                                                                  Social Security Number
                                                                                                      |        |        |        |        |        |        |        |        
  Street Address                                  City                                                                   State   ZIP Code

  Claim or Identification Number (if any) or Your Pension or Annuity Contract

  r 1.  I elect not to have income tax withheld from my pension or annuity. (If you check this box, do not complete Line 2.) 
 
  r 2.  I voluntarily elect to have the following amount withheld from each pension or annuity payment each month.  For  
               assistance in determining an amount to be withheld, visit our web site at http://dort.mo.gov/tax/calculators/withhold/.  
 
                            $ _____________________

               (The amount you enter cannot be less than $10.00 per month.)  

               Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
               Signature                                                                 Title                                    

  Signature    Printed Name                                                              Date (MM/DD/YYYY)
                                                                                         __ __ /__ __ /__ __ __ __

               1. Enter your full name, address and social security number.
               2. Enter your pension or annuity contract claim or identification number.
               3. If you do not wish to have Missouri state income taxes withheld from your pension or annuity income, place a check mark 
               in the box next to Line 1. Sign and date the form. Then send this form to the administrator of your retirement plan who will 
               simply keep your completed form on file.
               4. If you do wish to have Missouri state taxes withheld from your pension or annuity income, place a check mark in the box 
               next to Line 2. Then enter the amount you wish to have withheld monthly in the box provided. To determine the amount to 
               be withheld monthly, divide the amount of tax you paid with last year’s Missouri income tax return by twelve.  You may wish 
  Instructions to allow for the effect of any increases in your income from last year’s income by adjusting your calculation of the amount to 
               be withheld upwards. The amount to be withheld cannot be less than $10.00. Sign and date this form. Then send this form 
               to the administrator of your retirement plan who will then begin the withholding.
               5. Should you need to change this form or complete a new one, please contact the administrator of your retirement plan.

                                                                                                                                 Form MO W-4P  (Revised 11-2013)
                    Taxation Division             Phone: (573) 751-8750                          
                    P.O. Box 999                  TTY:  (800) 735-2966       Visit http://www.dor.mo.gov/business/withhold 
                    Jefferson City, MO 65108-0999 Fax: (573) 522-6816                    for additional information.