80024 IRA State Income Tax Withholding Election (12/2019)
The term IRA will be used below to mean Traditional IRA, Roth IRA, and SIMPLE IRA, unless otherwise specified. This form may only be used to supplement an IRA withdrawal form to make a state income tax withholding election. PART 1. IRA INFORMATION IRA OWNER Name (First/MI/Last) Social Security Number Date of Birth Phone Email Address ................
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