Unemployment Insurance Claimant Guide - Job Service North Dakota

VOLUNTARY TAX WITHHOLDING
JSND/Unemployment Insurance
SFN-59059 (R. 04-09)
Your unemployment insurance benefits are subject to federal and state income tax. You can choose to have
federal and state income tax withheld from your benefit amount.
Job Service North Dakota cannot refund these withholdings to you even if you return a check to us or have an
overpayment of unemployment benefits which you must repay. Withholdings can only be refunded by the IRS
and then only if you file and qualify for a refund on your annual income tax returns.
Income tax withholding from your unemployment insurance benefits is voluntary and is not required by law.
If you choose to have income taxes withheld, complete this form, tear it out of the guide, and return it by fax or mail
to Job Service North Dakota using the contact information below.
You may discontinue withholding at any time. If you choose to discontinue withholding, complete this form, tear it
out of the guide, and return it by fax or mail to Job Service North Dakota using the contact information below.
❑ Yes, I want federal income tax withheld from my Unemployment
Insurance benefit amount.
❑ Yes, I want federal and North Dakota state income tax withheld
from my Unemployment Insurance benefit amount.
❑ I want to discontinue federal or federal and North Dakota state
income tax withholdings from my Unemployment Insurance
benefit amount.
Signature: ________________________________________________________________
Social Security Number*: ____________________________________________________
Date: _________________________________________________________________
Return this form to:
Job Service North Dakota
Unemployment Insurance Claims Center
P.O. Box 5507
Bismarck, ND 58506-5507
or fax to 701-328-2728
*In compliance with the Privacy Act of 1974, a Social Security Number is mandatory on this form pursuant to 20 CFR 666.150 and/or North
Dakota Century Code 52-02-02. This number is used by Job Service North Dakota for identification, federal and state tax, program eligibility
purposes, and program performance accountability.
Job Service North Dakota is an equal opportunity employer/program provider. Auxiliary aids and services are available upon request to
individuals with disabilities.
JOB SERVICE NORTH DAKOTA Unemployment Insurance Claimant Guide 35