Arizona Form A-4c - Request For Reduced Withholding To Designate For Tax Credits - 2013
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1ARIZONA FORM
Request for Reduced Withholding to
2013
A-4C
Designate for Tax Credits
Employee’s Address
Employee’s City, State & ZIP code
Date
Employer’s (Company) Name
Employer’s Address
Employer’s City, State & 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 1
Entity 2
Entity 3
Entity Name
Entity Street Address
Entity City, State & ZIP code
Phone Number
Employer Identifi cation Number
(if known)
Annual Amount
$
.00
$
.00
$
.00
Check this box if additional entities are designated on an additional sheet.
I qualify for and am entitled to this amount of credit ($
.00) for 2013 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.
Thank you,
Employee’s Signature
Date
Print Name
For Employer Use Only
Approved by:
Date:
Total Contribution:
Pay periods:
Current withholding:
Amount per pay period
(not more than current):
Denied. Reason:
Employee Notifi ed
Yes
No
ADOR 10761 (12)
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