Form A1-Qtc - 2014 Quarterly Payment Of Reduced Withholding For Tax Credits
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1Quarterly Payment of
2014
Arizona Form A1-QTC
Reduced Withholding for Tax Credits
Please do not mail this form to the
This form is provided as a courtesy.
Arizona Department of Revenue.
You may send it or your own substitute to the
Employer’s Address – Number and street or PO Box
charity of your employee(s) choice.
Employer’s City, State and ZIP code
Do not file this form
with the Department of Revenue.
Date
TO:
Entity Name
Entity Address – Number and street or PO Box
Entity City, State and ZIP code
RE: Calendar Year 2014
Enclosed is $__________________ in payment of reduced withholding donations, made on behalf of all employees noted
below. Issue a receipt to each employee for the amount indicated.
EMPLOYEE 1
EMPLOYEE 2
EMPLOYEE 3
Employee’s Name:
Employee’s Street Address:
Employee’s City, State, ZIP Code:
Phone Number (with area code):
Amount Enclosed:
If this box is checked, additional forms are attached.
Please contact me if you have any questions.
Sincerely,
SIGNATURE OF PAYROLL DEPARTMENT REPRESENTATIVE
DATE
PRINT NAME
TITLE
TYPED NAME
COMPANY NAME
PHONE NUMBER (with area code)
E-MAIL ADDRESS
Please do not mail this form to the Arizona Department of Revenue.
ADOR 10762 (13)
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