Form Ar4pt - Nonresident Member Withholding Exemption Affidavit 2009
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1AR4PT
STATE OF ARKANSAS
Nonresident Member Withholding
Exemption Affidavit
CLICK HERE TO CLEAR FORM
PART A: Pass-Through Entity Information
Name of Entity
FEIN
Address
Type of Pass-Through Entity
S-Corporation
Trust
City, State, Zip
Partnership
Other
Limited Liability Co.
PART B: Nonresident Member Information
Name of Member
SSN or FEIN
Address
City, State, Zip
PART C: Withholding Tax Exemption
I, ______________________________________________, as a nonresident member of the above named
pass-through entity, request to be exempt from Arkansas income tax withholding per Arkansas Code Annotated
26-51-919(b)(1)(A) for tax year ______________________, and all subsequent years, until I notify the Arkansas
Department of Finance and Administration of a change in this election (see Part D.)
By signing this affidavit I agree to be subject to the personal jurisdiction of the Arkansas Department of Finance
and Administration in the courts of this state for the purpose of determining and collecting any Arkansas taxes,
including estimated tax payments, together with any related interest and penalties.
I agree to timely file appropriate income tax returns, or be included in the pass-through entity’s income tax return,
and make payment of all Arkansas taxes as required by law.
If I fail to abide by the terms of this affidavit I understand that the Arkansas Department of Finance and
Administration may revoke at any time the withholding exemption granted under Arkansas Code Annotated
26-51-919(c)(5)(B).
PART D: Withholding Tax Exemption Revocation
I, ______________________________________________, as a nonresident member of the above named
pass-through entity, hereby revoke my previous withholding election dated _______________.
At this time, I request to be subject to income tax withholding on my share of distributed Arkansas income of
the above named pass-through entity for tax year _______, and all subsequent years, until I notify the Arkansas
Department of Finance and Administration of a change of this election.
PART E: Signature
____________________________________________________________
______________________
Signature of Nonresident Member
Date
Daytime Telephone Number __________________
AR4PT (R 10/29/09)
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