ARIZONA FORM
2013
Voluntary Withholding Request for
A-4V
Arizona Resident Employed Outside of Arizona
Type or print your full name (last, fi rst, middle initial)
Your social security number
Home address (number and street or rural route)
City or town, state, and ZIP code
Voluntary Arizona Income Tax Withholding Options
Choose only one:
1
I am an Arizona resident employed outside of Arizona. I hereby elect to have Arizona income taxes withheld from my compensation paid for
services performed outside of Arizona for my employer as authorized by ARS §43-408. I choose to have Arizona withholding at the rate of
(check only one box):
0.8%
1.3%
1.8%
2.7%
3.6%
4.2%
5.1%
of my
gross taxable wages.
Additional amount to be withheld per paycheck $
2
I am an Arizona resident employed outside of Arizona. I hereby elect to terminate my prior election for voluntary Arizona income tax
withholding from my compensation paid for services performed outside of Arizona for my employer.
I certify that I have made the percentage election marked above.
EMPLOYEE’S SIGNATURE
DATE
GENERAL INSTRUCTIONS
Who May Use Form A-4V
What are my “Gross Taxable Wages”?
Arizona Form A-4V is for Arizona resident employees who are
For withholding purposes, “gross taxable wages” are the wages from
performing work outside of Arizona. Use this form to request that your
each paycheck that will generally be in box 1 of your federal Form W-2.
employer withhold Arizona income taxes from your wages for work
It is your gross wages less any pretax deductions, such as your share
done outside of Arizona. This amount is applied to your Arizona income
of health insurance premiums.
tax due when you fi le your return. Your employer is not required by
What Should I do With Form A-4V?
statute to grant your request.
Complete this form to request that your employer withhold Arizona
If your employer agrees to withhold Arizona income tax from your
income tax from your wages and elect an Arizona withholding
wages, Arizona withholding is a percentage of your gross taxable
percentage and any additional amount to be withheld from each
wages of every paycheck. You may also have your employer withhold
paycheck. Give your completed form to your employer.
an additional amount from each paycheck.
EMPLOYER CERTIFICATION
, the employer of an Arizona resident,
,
(NAME OF EMPLOYER - COMPANY OR INDIVIDUAL)
(EMPLOYEE’S NAME)
whose compensation is for services performed outside of Arizona, has agreed to withhold Arizona income taxes from the employee’s compensation as
authorized by ARS §43-408. As stated in ARS §43-408(B), the employer understands and agrees that the employer and the employee are subject to
the provisions of Chapter 4 of Title 43 of the Arizona Revised Statutes, as if the employer were required to withhold Arizona income taxes from such
compensation.
SIGNATURE OF OFFICER, SOLE PROPRIETOR, OR AGENT
TITLE
DATE
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ADOR 10372 (12)