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AR8453-CR

2016

CREF161

ARKANSAS COMPOSITE TAX RETURN

DECLARATION FOR ELECTRONIC FILING

For calendar year 2016, or tax year beginning

, 20

, ending

, 20

Name of Entity

Federal Identification Number

Mailing Address

Telephone

City

State or Province

ZIP

Country

(if not U.S.)

PART 1

TAX RETURN INFORMATION (Whole Dollars Only)

Taxable Income from Schedule A (Form AR1000CR, Line 1) ...................................................................................

Tax (Form AR1000CR, Line 2)..................................................................................................................................

Arkansas Income Tax Withheld (Form AR1000CR, Line 3) ......................................................................................

Amount of Overpayment/Refund (Form AR1000CR, Line 10)..................................................................................

Amount Due (Form AR1000CR, Line 13) .................................................................................................................

PART 2

DECLARATION OF OFFICER (Sign only after Part I is completed)

6a.

I authorize the State of Arkansas, Income Tax Section to initiate debit entries to my account as indicated on the Arkansas Income Tax Payment

for (AR TAX PMT).

6b.

I authorize the State of Arkansas, Income Tax Section to initiate debit entries to my account as indicated on the Arkansas Estimated Tax

Payment form (AR EST PMT) or Arkansas Extension Payment form (AR EXT PMT).

Under penalties of perjury, I declare that I am an officer, partner or accountant for the above entity and that the information I have given my electronic

return originator (ERO), transmitter, and/or internet service provider (ISP) and the amounts in Part I above agree with the corresponding lines on the 2016

Arkansas composite return. To the best of my knowledge and belief, the composite return is true, correct, and complete. I consent to my ERO, transmitter,

and/or ISP sending the composite return, this declaration, and accompanying schedules and statements to the State of Arkansas. I also consent to the

State of Arkansas sending my ERO, transmitter, and/or ISP an acknowledgment of receipt of transmission and an indication of whether or not the composite

return is accepted, and, if rejected, the reason(s) for the rejection. If the processing of the composite return is delayed, I authorize the State of Arkansas to

disclose to my ERO, transmitter, and/or ISP the reason(s) for the delay, or when the refund was sent. In addition, by using a computer system and software

to prepare and transmit my return electronically, I consent to the disclosure to the State of Arkansas of all information pertaining to my use of the system

and software and to the transmission of my tax return electronically.

Sign

Here

Signature of officer, partner or accountant

Date

Title

PART 3

DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER

I declare that I have reviewed the above composite return and that the entries on Form AR8453-CR are complete and correct to the best of my knowledge.

If I am only a collector, I understand that I am not responsible for reviewing the composite return; I declare that Form AR8453-CR accurately reflects the

data on the return. I have obtained the officer, partner or accountant’s signature on Form AR8453-CR before submitting this return to the State of Arkansas,

and have provided the officer, partner or accountant with a copy of all forms and information to be filed with the State of Arkansas. If I am also the Paid

Preparer, under penalties of perjury I declare that I have examined the above composite return and accompanying schedules and statements, and to the

best of my knowledge and belief, the are true, correct, and complete. This declaration of Paid Preparer is based on all information of which the preparer

has knowledge.

ERO’s

Date

Check if also

Check if

ERO’s SSN or PTIN

ERO’S

signature

paid preparer

self-employed

Use

Firm’s name (or yours