Arizona Form A1-C - Arizona Charitable Withholding Statement - 2013 Page 2
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EIN:
AZ Form A1-C (2013)
Page
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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)
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)
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