INSTRUCTIONS: ANNUITANT'S REQUEST FOR VOLUNTARY ARIZONA INCOME TAX WITHHOLDING (Form A-4P)

Arizona residents receiving an annuity or pension may elect to have state income tax voluntarily withheld from their payments. This document can be obtained from the website of the Arizona Department of Revenue. You may not elect to have income taxes withheld from nonperiodic payments, lump sum distributions, or individual retirement account distributions.

Annuitant's Request For Voluntary Arizona Income Tax Withholding A-4P Step 1: On the first line of the table at the top of the form, enter your full name and Social Security number.

Annuitant's Request For Voluntary Arizona Income Tax Withholding A-4P Step 2: On the second line, enter your home address and annuity contract claim or I.D. number.

Annuitant's Request For Voluntary Arizona Income Tax Withholding A-4P Step 3: On the third line, enter your city or town, state and zip code, as well as your telephone number.

Annuitant's Request For Voluntary Arizona Income Tax Withholding A-4P Step 4: Check the box on line 1 if you wish to have this income tax withheld. You should also indicate with a check mark your preferred percentage rate of 0.8%, 1.3%, 1.8%, 2.7%, 3.6%, 4.2% or 5.1%. You may also enter an additional dollar amount you wish to have withheld from every payment.

Annuitant's Request For Voluntary Arizona Income Tax Withholding A-4P Step 5: Check the box on line 2 if you wish to terminate a previously elected withheld tax.

Annuitant's Request For Voluntary Arizona Income Tax Withholding A-4P Step 6: Sign and date the form.

Annuitant's Request For Voluntary Arizona Income Tax Withholding A-4P Step 7: Once you have completed this document, send it to the payor of your annuity or pension. Do not send a copy to the Arizona Department of Revenue.

Annuitant's Request For Voluntary Arizona Income Tax Withholding A-4P Step 8: Once the payor puts this A-4P form into effect, it will remain in effect unless you change this status. You may do so by sending another form A-4P or sending a written notice requesting termination of withholding.

Annuitant's Request For Voluntary Arizona Income Tax Withholding A-4P Step 9: You should be provided by your payor with a statement documenting your payments received and taxes withheld at the beginning of the successive tax year.