Form Ar4ecsp - Employee'S Special Withholding Exemption Certificate

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STATE OF ARKANSAS

AR4ECSP

Employee’s Special Withholding Exemption Certificate

Employee’s Full Name _________________________________________________________SSN_____________________________

Home Address_____________________________________________City _______________State ______________Zip ___________

Employee:

File this form with your employer.

CHECK THE APPLICABLE BLOCK:

This will exempt your earnings from State

[

]

I am single and my gross income will not exceed $7,700.

income tax withholding.

[

]

I am married and jointly filing with my spouse and our combined gross

income will not exceed $15,000.

Employer: Keep this certificate with your records.

[

]

I am Unmarried Head of Household and my gross income will not

exceed $12,000.

Under penalty of perjury, I certify that the above information is true and if there is any change in my status, I will notify my employer immediately.

DATE _________________________________, 19 _____________SIGNED ____________________________________________

AR4SCSP (11/98)