Arizona Form A1-C - Arizona Charitable Withholding Statement - 2013

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Arizona Form A1-C
Arizona Charitable Withholding Statement
Arizona Department of Revenue
Offi ce of Economic Research and Analysis
Due on or before January 30, 2014.
PO Box 25248 - Phoenix AZ 85002-5248
EIN:
Please do not mail with Form A1-R or Form A1-APR.
Period End:
12/31/2013
I.
Employer Information
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
Name
Number and street or PO Box
City or town, state, and ZIP code
POSTMARK DATE
Business telephone number
(
)
Amended Statement
Address Changed
Check box if:
II. Payments Made on Behalf of Employees
(Attach continuation sheet(s), if necessary):
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 identifi cation number
Employee’s Social Security number
Charity’s Federal identifi cation 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
made in 2013.
made in 2013.
(if applicable).
(if applicable).
2013
2013
$
$
ADOR 10754 (12)
ADOR 10754 (12)
CORRECTED (if checked)
CORRECTED (if checked)
III. Explain why an amended Form A1-C is being fi led (attach additional sheet, if necessary):
Send Form and any attachments to: Arizona Department of Revenue, Offi ce of Economic Research and Analysis,
PO Box 25248, Phoenix AZ 85002-5248
Under penalties of perjury, I declare that I have examined this statement and to the best of my knowledge and belief, it is true, complete and correct.
Please
(
)
Sign Here
Employer’s signature
Date
Business telephone number
Paid
Preparer’s
Preparer’s signature
Date
Preparer’s PTIN
Use Only
Firm’s name (or preparer’s, if self-employed)
Firm’s
EIN or
SSN
(
)
Firm’s address
Zip code
Firm’s telephone number
DRAFT #___, Jul-23-12
DRAFT #___, Jul-23-12
ADOR 10754 (12)
Draft 8/27/2012

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