Form Ar4pt-A - Transmittal Of Nonresident Member Withholding Exemption Affidavit
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1AR4PT-A
STATE OF ARKANSAS
Transmittal of Nonresident Member Withholding
Exemption Affidavit
CLICK HERE TO CLEAR FORM
Name of Entity
FEIN
Address
Name of Contact Person
City, State and ZIP
Contact Person’s Telephone Number
Type of Media (check one)
Diskette
CD
Paper
To assist us in processing your information accurately, please use this form as a cover for the transmittal of
the diskette(s) or CD(s) containing the affidavit information or for the transmittal of the paper copies of Form(s)
AR4PT.
Please label the diskette or CD with the name of the pass-through entity, the Federal Identification Number and
the number of records. If your information resides on more than one diskette or CD, each must be labeled:
1 of ___, 2 of ___, etc.
Attach the diskette, CD or Form(s) AR4PT to this form and mail to the address below on or before the due date
of the pass-through entity’s income tax return, including extensions.
For those taxpayers that have received a waiver from the filing of the nonresident member information by CD
or diskette, copies of all Nonresident Member Withholding Exemption Affidavits (Form AR4PT) must be filed
with this form and mailed to the address below on or before the due date of the pass-through entity’s income
tax return, including extensions.
Note: This form must not be included or attached to any other documents or tax forms being mailed
to the Arkansas Department of Finance and Administration. Please mail independently of other
report or form filings.
Mail to:
Individual Income Tax Section
Pass-Through Entity
Post Office Box 3628
Little Rock, AR 72203-3628
AR4PT-A (R 10/23/07)
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