Form Ar4ecsp - State Of Arkansas Employees'S Special Withholding Exemption Certificate

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AR4ECSP
State of Arkansas
Employees'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 for your records.
CHECK THE APPLICABLE BLOCK:
I am single and my gross income from all sources will not exceed $10,941.00.
I am married filing jointly with my spouse, have 1 or less dependents, and our
combined gross income from all sources will not exceed $18,449.00
I am married filing jointly with my spouse, have 2 or more dependents, and our
combined gross income from all sources will not exceed $22,203.00
I am unmarried filing Head of Household or a Qualifying Widow(er), have 1 or less
dependents, and my gross income from all sources will not exceed $15,553.00
I am unmarried filing Head of Household or a Qualifying Widow(er), have 2 or more
dependents, and my gross income from all sources will not exceed $18,540.00
Under penalty of perjury, I certify the above information is true and if there is a change in my status, I will notify my employer immediately.
Signature
Date
Revised 08/29/2012

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