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State Income Tax from pension or annuity income only. This form is to be provided to the administrator of your retirement plan DO NOT SEND TO THE DEPARTMENT OF REVENUE. FULL NAME (TYPED OR PRINTED) SOCIAL SECURITY NUMBER CLAIM OR IDENTIFICATION NUMBER (IF ANY) OR YOUR PENSION OR ANNUITY CONTRACT. STREET ADDRESS CITY OR TOWN, STATE, ZIP CODE COMPLETE THE FOLLOWING APPLICABLE LINES 1. I elect NOT to have income tax withheld from my pension or annuity. (If you check this box, do.

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