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

Form Ar4ecsp Draft - Employee'S Special Withholding Exemption Certificate

AR4ECSP

STATE OF ARKANSAS

Employee’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 with your records.

CHECK THE APPLICABLE BLOCK:

[ ] I am single and my gross income from all sources will not exceed $7,800.

[ ] I am married filing jointly with my spouse, and

our combined gross income from all sources will not exceed $15,500.

[ ] I am unmarried filing Head of Household or a Qualifying Widow(er), and

my gross income from all sources will not exceed $12,100.

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

employer immediately.

Signature ________________________________________________________ Date __________________________

(Rev 12/2/09)

Form Ar4ecsp Draft - Employee'S Special Withholding Exemption Certificate