Form Ar4ecsp - Employee'S Special Withholding Exemption Certificate
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1AR4ECSP
STATE OF ARKANSAS
Employee’s Special Withholding Exemption Certificate
Employee’s Full Name
SSN
__________________________________________________________________
_________________________
Home Address
City
State
Zip
_________________________________________________
____________________________
____
________
Employee: File this form with your employer to exempt your earnings from State income tax withholding.
Employer: Keep this certificate with your records.
CHECK THE APPLICABLE BLOCK:
[ ] I am single and my gross income from all sources will not exceed $10,681.
[ ] I am married filing jointly with my spouse, have 1 or less dependents, and
our combined gross income from all sources will not exceed $18,011.
[ ] I am married filing jointly with my spouse, have 2 or more dependents, and
our combined gross income from all sources will not exceed $21,676.
[ ] I am unmarried filing Head of Household or a Qualifying Widow(er), and
my gross income from all sources will not exceed $15,184.
Under penalty of perjury, I certify that the above information is true and if there is a change in my status, I will notify my
employer immediately.
Signature ________________________________________________________ Date __________________________
(Rev 01/24/11)
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