IOWA WORKFORCE DEVELOPMENT
Tax Withholding Agreement
60-0360 (08-2009)
Equal Opportunity Employer/Program
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Local Office Use
380 Federal 2 = Y 1 = No
381 State 2 = Y 1 = No
Station Desk
Social Security Number
First Name MI
Last Name
I hereby authorize Iowa Workforce Development to start or change withholding the following income taxes
from my unemployment benefits.
FEDERAL withholding equal to 10 percent of my gross weekly benefit payment.
1. No (Stop)
2. Yes (Start)
1. No (Stop)
2. Yes (Start)
IOWA withholding equal to 5 percent of my gross weekly benefit payment.
If you are paid $10.00 or more in unemployment insurance benefits, Iowa Workforce Development will mail
a form 1099-G listing the amount of benefits paid to your address of record by January 31. The 1099-G
also will list the amount(s) of any federal and/or state taxes withheld the previous year.
Claimant Signature________________________________________ Date Signed__________________
Complete and make a copy for your files. Return original to: Iowa Workforce Development Center
Unemployment Insurance Service Center
P.O. Box 10332
Des Moines, IA 50306-0332
Administrative Use Only
O.C. Date
Print Form
