Arizona Form A-4c - Request For Reduced Withholding To Designate For Tax Credits - 2016
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1Arizona Form
2016
A-4C
Request for Reduced Withholding to Designate for Tax Credits
Please do not mail this form to the Arizona Department
of Revenue. Provide it to your employer.
Employee’s Address – Number and street or PO Box
Employee’s City, State and ZIP Code
Date
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), and school tuition
organization(s) [entity]:
Entity Name
Employer Identification No. (if known)
Entity Street Address
Phone No. (with area code)
ENTITY 1
Entity City
State
ZIP Code
Annual Amount:
Entity Name
Employer Identification No. (if known)
Entity Street Address
Phone No. (with area code)
ENTITY 2
Entity City
State
ZIP Code
Annual Amount:
Entity Name
Employer Identification No. (if known)
Entity Street Address
Phone No. (with area code)
ENTITY 3
Entity City
State
ZIP Code
Annual Amount:
If this box is checked, additional entities are designated on an additional sheet.
I qualify for and am entitled to this amount of credit ($_____________.00) for 2016 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 and/or 348 for credit limits.
EMPLOYEE’S SIGNATURE
DATE
PRINT NAME
TYPE 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
Please do not mail this form to the Arizona Department of Revenue.
ADOR 10761 (15)
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Parent category: Financial