Withholding Certificate for Pension Payment from the
CITY OF HOLLYWOOD EMPLOYEES’ RETIREMENT FUND
Effective Date of Election: ____________________
Note: Pursuant to Section 119.071(5)(a)2, Florida Statutes, your social security number is requested for the purpose of determining eligibility for retirement benefits as a plan member, retiree or beneficiary; the processing of retirement benefits; verification of retirement benefits; income reporting; or other notice or disclosures related to retirement benefits. Your social security number will be used solely for one or more of these purposes.
Type or print your name: ____________________________________________
Your Social Security Number: ________________________________________
Street Address or PO Box, City, State, Zip:
Complete the following applicable lines:
1. I do not want any Federal income tax withheld from my pension (skip Items 2-4).
2. I want a fixed amount withheld from my pension payment: $_____________ (skip Items 3 and 4).
3. I want to use the IRS tax tables to calculate my withholding. Number of exemptions claimed:________. Marital Status used: Married; Single; Married, but withhold at higher “Single” rates.
4. Additional monies to withhold: $____________
Your Signature Date Signed
Return form to: City of Hollywood Employees' Retirement Fund
c/o Lisa Castronovo, Pension Coordinator
PO Box 229045
Hollywood, FL 33022-9045