Form Ar4ecsp - Employees'S Special Withholding Exemption Certificate printable pdf download

Form Ar4ecsp - Employees'S Special Withholding Exemption Certificate

AR4ECSP

State of Arkansas

Employees's Special Withholding Exemption Certificate

Employee's Full Name:

SSN:

Home Address:

City:

State:

Zip:

Employee: File this form with your employer to exempt your earnings from State income tax withholding.

Employer: Keep this certificate for your records.

CHECK THE APPLICABLE BLOCK:

I am single and my gross income from all sources will not exceed $11,222.00.

I am married filing jointly with my spouse, have 1 or less dependents, and our

combined gross income from all sources will not exceed $18,923.00

I am married filing jointly with my spouse, have 2 or more dependents, and our

combined gross income from all sources will not exceed $22,774.00

I am unmarried filing Head of Household or a Qualifying Widow(er), have 1 or less

dependents, and my gross income from all sources will not exceed $15,953.00

I am unmarried filing Head of Household or a Qualifying Widow(er), have 2 or more

dependents, and my gross income from all sources will not exceed $19,017.00

Under penalty of perjury, I certify the above information is true and if there is a change in my status, I will notify my employer immediately.

Signature

Date

Revised 01/03/2013

Form Ar4ecsp - Employees'S Special Withholding Exemption Certificate