Form A1-Qrt(Ez) - Arizona Quarterly Withholding Tax Return (Short Form)
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1
2A1-QRT(EZ)
305
Arizona Quarterly Withholding Tax Return (Short Form)
310
B/D
THIS FORM IS USED ONLY BY EMPLOYERS THAT HAVE A QUARTERLY OR MONTHLY
WITHHOLDING TAX LIABILITY. A monthly tax liability employer that incurs a one-banking
day withholding tax liability during any month of the calendar quarter must use the Form
A1-QRT.
P/M
Send to: Arizona Department of Revenue, PO Box 29009, Phoenix AZ 85038-9009
Make checks payable to: Arizona Department of Revenue
State Withholding Number
Failure to make payment may result in a 25% penalty in addition to other penalties and
interest required by law.
For certain taxpayers, Arizona law requires that withholding taxes be paid at the same time as
Qtr
Year
Amended
federal withholding deposits are due. (See instructions)
Amount of Payment Enclosed
Name
Please
C/O
Dollars
Cents
Prior Payments Made for This Quarter
Type
Number and street
or
Print
Cents
Dollars
City, or town, state, and ZIP code
Total Payments for This Quarter
Cents
Dollars
q
Check this box to cancel withholding account. Complete the explanation section on
page 2. (See instructions). Enter date nal wages paid __________________________
Total Federal Income Tax Withheld This
Total Arizona
Payroll This Quarter
Quarter For Arizona Employees (Without FICA)
FEIN
Complete either the monthly tax liability section (AA, BB, CC) or the quarterly tax liability section (DD).
Enter Total of AA, BB and CC or Amount from DD
1st Month AA
Monthly
Quarterly
Total
Tax
Tax
Liability
2nd Month BB
Liability
Liability
for Quarter
3rd Month CC
DD
Z
Under penalties of perjury, I declare that I have examined this return and to the best of my knowledge and belief, it is a true, complete and
correct return.
(
)
Please
________________________________________________________________________________________________
________________________________
Sign Here
Signature
Date
Business telephone number
Paid
(
)
________________________________________________________________________________________________
________________________________
Preparer’s
Preparer’s signature
Date
Business telephone number
Use Only
___________________________________________________________________________________________________________________________________
Firm’s name (or preparer’s, if self-employed)
Preparer’s EIN, SSN, or PTIN
___________________________________________________________________________________________________________________________________
Firm’s address
Zip code
Complete page 2 if amended return box is checked OR if the account cancellation box is checked.
ADOR 91-1061 (02)
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