Form C4 - Application For Normal Retirement - 2011 Page 18
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22Annuitant’s Request for
2012
ARIZONA FORM
A-4P
Voluntary Arizona Income Tax Withholding
Type or print your full name (last, fi rst, middle initial)
Your social security number
Home address (number and street or rural route)
Annuity Contract Claim or I.D. Number
City or town, state, and ZIP code
Telephone Number
Annuitant’s Voluntary Arizona Income Tax Withholding Options
Choose only one:
…
I hereby elect to have Arizona income taxes withheld from my annuity or pension payments as authorized by ARS §43-404.
1
I choose to have Arizona withholding at the rate of
…
…
…
…
…
…
…
0.8%
1.3%
1.8%
2.7%
3.6%
4.2%
5.1% of the
(check only one box):
taxable amount of distribution.
Additional amount to be withheld per distribution $
…
I hereby elect to terminate my prior election for voluntary Arizona income tax withholding from my annuity or pension payments as
2
authorized by ARS §43-404.
I certify that I have made the percentage election marked above.
SIGNATURE
DATE
Print
Reset Form
GENERAL INSTRUCTIONS
Who May Use Form A-4P
Where to Send Form A-4P
A person who receives an annuity or pension may use this form to
Send Form A-4P to the payor of your annuity or pension. Do not send
elect voluntary Arizona income tax withholding. Arizona withholding is
Form A-4P to the Arizona Department of Revenue.
a percentage of the taxable amount of distribution in Box 2a of federal
Duration of Voluntary Arizona Withholding Election
Form 1099-R. Therefore, you may elect voluntary Arizona income
The payor of your pension or annuity will withhold Arizona income tax
tax withholding at the applicable percentage rates and designate an
from your payments until you notify the payor to terminate Arizona
additional amount to be withheld.
withholding.
“Annuity” means any amount paid to an individual as a pension or
How to Terminate a Voluntary Arizona Withholding Election
annuity, but only to the extent that the amount is includible in the Arizona
gross income of that individual.
You may terminate your voluntary Arizona withholding election at any
time. You may use Form A-4P to terminate Arizona withholding or
You may NOT elect to have Arizona income tax withheld from
you may send a written notice to the payor of your pension or annuity
nonperiodic payments, lump sum distributions, or individual retirement
requesting termination of withholding.
account distributions, that do not meet the defi nition of annuity listed
Statement of Income Tax Withheld
above.
The payor of your pension or annuity will provide you with a form that
You also may NOT elect to have Arizona income tax withheld from
lists the total amount of your pension or annuity payments and the total
Social Security pensions, Veteran’s Administration annuities, or
amount of Arizona income tax withheld from these payments for the
Railroad Retirement pensions.
calendar year 2012. The payor of your pension or annuity will provide
this form to you in early 2013.
ADOR 10122 (11)
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