Form A-4p(Cs) - Civil Service Annuitant'S Request For Arizona Income Tax Withholding
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1Civil Service Annuitant's Request for
ARIZONA FORM
A-4P(CS)
Arizona Income Tax Withholding
Rev (97)
Type or print clearly
Last name
First
Middle initial
Social security number
Home address (number and street)
Annuity contract claim or identification number
City, state, and ZIP code
Telephone number
(
)
A. This is my initial enrollment (fill out line D below) ....................................
CHECK ONE
B. I wish to cancel my enrollment ................................................................
BOX ONLY
C. I already have a deduction. This request will be an: Increase ................
(fill out line D below)
Decrease ...............
D. The exact amount of my Arizona monthly withholding should be: $ ____________________
NOTE: WITHHOLDING AMOUNT MUST BE ROUNDED TO A WHOLE DOLLAR (NO CENTS) AND BE GREATER THAN FIVE DOLLARS.
(Date)
(Signature of Annuitant)
This form must be filed with the Arizona Department of Revenue.
Do not file this form with the Office of Personnel Management.
INSTRUCTIONS
Who May File. Any person that receives federal civil service
If you are not canceling your enrollment, you must complete line
annuity or pension payments may file this form to have Arizona
D or your request will be returned to you. The amount must be
income tax withheld from each payment. However, you must
rounded to a whole dollar (no cents) and be greater than five
first elect to have federal withholding.
dollars.
You may not request withholding of Arizona income tax on
Duration of Withholding. Voluntary withholding will remain in
social security pensions, Veterans Administration annuities, or
effect until canceled.
Railroad Retirement pensions.
How To Cancel Withholding. You may cancel your voluntary
Where and How To File. Make a copy for your records and file
withholding at any time. Complete line B to stop your
this form with the:
withholding.
Data Management Division
Statement of Income Tax Withheld. After the end of the year
Arizona Department of Revenue
the Office of Personnel Management will furnish you with a form
1600 W Monroe
showing the gross amount of annuity or pension payments. This
Phoenix AZ 85007-2650
statement will also show the total amount deducted and
withheld as tax during the calendar year.
ADOR 06-0043 (97)
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