Arizona Form A1-C Draft - Arizona Charitable Withholding Statement - 2014
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1
2Arizona Form A1-C
Arizona Charitable Withholding Statement
Arizona Department of Revenue
Due on or before January 30, 2015.
Office of Economic Research and Analysis
EIN
PO Box 29099 - Phoenix AZ 85038-9099
Period End
Please do not mail with Form A1-R or Form A1-APR.
12/31/2014
I. Employer Information
Name
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
88
Number and street or PO Box
City or town, state and ZIP Code
PM
RCVD
Business telephone number (with area code)
81
66
Check box if:
Amended Statement
Address Changed
II. Payments Made on Behalf of Employees (if necessary, attach continuation sheet(s))
Charitable Withholding Statement
Charitable Withholding Statement
Charity’s name, street address, city, state, and ZIP code
Charity’s name, street address, city, state, and ZIP code
Charity’s Federal identification number
Employee’s Social Security number
Charity’s Federal identification number
Employee’s Social Security number
Employee’s name
Employee’s name
Street address (including apt. no.)
Street address (including apt. no.)
City, state, and ZIP code
City, state, and ZIP code
1 Employee contributions
2 Termination date
1 Employee contributions
2 Termination date
2014
2014
made in 2014.
made in 2014.
(if applicable).
(if applicable).
$
$
ADOR 10754 (13)
ADOR 10754 (13)
CORRECTED (if checked)
CORRECTED (if checked)
III. Explain Why an Amended Form A1-C is Being Filed (if necessary, attach additional sheet)
Send form and any attachments to:
Arizona Department of Revenue, Office of Economic Research and Analysis,
PO Box 29099, Phoenix, AZ 85038-9099
Under penalties of perjury, I declare that I have examined this statement and to the best of my knowledge and belief, it
Declaration
is true, complete and correct.
Please
(
)
Sign Here
EMPLOYER’S SIgNATURE
DATE
BUSINESS PhONE NUMBER
PAID PREPARER’S SIgNATURE
DATE
PAID PREPARER’S PTIN
Paid
Preparer’s
FIRM’S NAME (OR PAID PREPARER’S NAME, IF SELF-EMPLOYED)
FIRM’S
EIN OR
SSN
Use
(
)
Only
FIRM’S STREET ADDRESS
FIRM’S PhONE NUMBER.
CITY
STATE
ZIP CODE
DRAFT #2, Aug-1-13
ADOR 10754 (13)
DRAFT #1, Aug-27-13
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