Arizona Form A1-Qtc - Quarterly Payment Of Reduced Withholding For Tax Credits - 2013

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ARIZONA FORM
Quarterly Payment of Reduced Withholding
2013
A1-QTC
for Tax Credits
This form is provided as a courtesy.
You may send it or your own
substitute to the charity of your
Employer’s Address
employee(s) choice.
Employer’s City, State & ZIP code
Do not file this form with the
Department of Revenue.
Date
Re: Calendar Year 2013
Entity Name
Entity Address
Entity City, State & ZIP code
Enclosed is $
in payment of reduced withholding donations, made on behalf of all employees
noted below. Issue a receipt to each employee for the amount indicated.
Employee 1
Employee 2
Employee 3
Employee’s Name
Employee’s Street Address
Employee’s City, State & ZIP
code
Phone Number
Amount Enclosed
$
$
$
A check in this box indicates additional forms are attached.
Please contact me if you have any questions.
Thank you,
Payroll Department Representative
Date
Print Name
Title
Company Name
Phone Number
E-mail Address
Print
ADOR 10762 (12)

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