Form Ub-433 - Voluntary Election For Federal/state Income Tax Withholding
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
UB-433 (5-17)
Workforce Administration • Unemployment Insurance Program
VOLUNTARY ELECTION FOR FEDERAL/STATE INCOME TAX WITHHOLDING
State law provides that you can have an amount equal to 10% of your maximum weekly benefit amount withheld from your
unemployment insurance benefits for Federal income tax and 10% of the Federal deduction amount withheld for State
income tax.
You can have both Federal and State income taxes withheld, or Federal tax withheld, but you cannot have only the State
tax withheld.
ATTENTION: If you opt to have taxes withheld and then change your mind, you cannot recoup any money that was
withheld.
The tax will be deducted from the benefit amount remaining after any earnings, pension, or overpayment offset amounts
are deducted.
Please mark the applicable box:
Do not withhold any income taxes.
Withhold Federal and State income taxes.
Withhold Federal income tax only.
Discontinue withholding State income tax.
Discontinue withholding Federal and State income tax.
CLAIMANT’S INFORMATION
NAME
(Last, First, M.I.)
SOCIAL SECURITY NUMBER
SIGNATURE
DATE
ADDRESS
(Number, Street)
CITY
STATE
ZIP CODE
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Administracíon para la Fuerza Laboral • Programa de Seguro por Desempleo
OPCION VOLUNTARIA DE RETENCION DE IMPUESTOS FEDERAL/ESTATAL
La ley estatal dispone la opción de una cantidad equivalente y que 10% de su beneficio de seguro por desempleo
semanal sea retenida para el impuesto Federal, y que un 10% de la deducción Federal sea retenida como impuesto
Estatal.
Usted puede seleccionar que ambos impuestos Federal y Estatal sean retenidos, o que sólo el impuesto Federal sea
retenido, pero no puede seleccionar la deducción de solamente el impuesto Estatal.
ATENCIÓN: Si selecciona retención de impuestos y luego cambia de idea, no podrá recobrar ninguna parte del
dinero retenido.
El impuesto será deducido de la cantidad sobrante de su beneficio luego de la substracción de cualquier cantidad por
ganancias, pagos de pensión, o balance de un sobrepago.
Favor de marcar la cajita correspondiente:
No retenga los impuestos.
Retenga impuestos Federales y Estatales.
Retenga impuesto Federal solamente.
Descontinúe la retención de impuesto Estatal.
Descontinúe la retención de ambos impuestos Federales y Estatales.
INFORMACIÓN DEL RECLAMANTE
NOMBRE
(Apellido, Nombre de pila, Inicial)
NUMERO DE SEGURO SOCIAL
FIRMA
FECHA
DOMICILIO
(Número, Calle)
CIUDAD
ESTADO
CÓDIGO POSTAL
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