Arizona Form A-4c - Request For Reduced Withholding To Designate For Tax Credits - 2017
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1Arizona Form
2017
A-4C
Request for Reduced Withholding to Designate for Tax Credits
Do not mail this form to the Arizona Department of
Revenue. Provide it to your employer.
Employee’s Name
Employee’s Address – Number and street or PO Box
Employee’s City, State and ZIP Code
TO:
Employer’s (Company) Name
Employer’s Address – Number and street or PO Box
Employer’s City, State and ZIP Code
At my employer’s option, I request that my withholding be reduced in accordance with Arizona Revised Statutes (A.R.S.)
§ 43‑401(G) and that quarterly payments be made on my behalf to the following charity(ies), school(s), or school tuition
organization(s) [entity]:
QUALIFYING CHARITIES, PUBLIC SCHOOLS, OR SCHOOL TUITION ORGANZATIONS
Entity Name
Employer Identification No. (if known)
Entity Street Address
Phone No. (with area code)
FIRST
ENTITY
Entity City
State
ZIP Code
Annual Amount:
Entity Name
Employer Identification No. (if known)
Entity Street Address
Phone No. (with area code)
SECOND
ENTITY
Entity City
State
ZIP Code
Annual Amount:
Entity Name
Employer Identification No. (if known)
Entity Street Address
Phone No. (with area code)
THIRD
ENTITY
Entity City
State
ZIP Code
Annual Amount:
If this box is checked, additional entities are designated on a separate sheet.
I qualify for and am entitled to this amount of credit ($_____________.00) for 2017 under A.R.S. §§ 43‑1088, 43‑1089,
43‑1089.01 and/or 43‑1089.03. Refer to the instructions for Arizona Forms 321, 322, 323, 348, and/or 352 for credit limits.
EMPLOYEE’S SIGNATURE
DATE
PRINT NAME
FOR EMPLOYER USE ONLY
Approved by:
Date
Total Contribution
Pay Periods
Current Withholding
Amount Per Pay Period (not more than current):
$
$
$
Denied – Indicate reason:
Employee Notified:
Yes
No
Do not mail this form to the Arizona Department of Revenue. Provide it to your employer.
ADOR 10761 (16)
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