
2012
Type or print your full name (last, fi rst, middle initial) Your social security number
Home address (number and street or rural route) Annuity Contract Claim or I.D. Number
City or town, state, and ZIP code Telephone Number
Annuitant’s Voluntary Arizona Income Tax Withholding Options
Choose only one:
1 ! I hereby elect to have Arizona income taxes withheld from my annuity or pension payments as authorized by ARS §43-404.
I choose to have Arizona withholding at the rate of
(check only one box):
!
0.8%
!
1.3%
!
1.8%
!
2.7%
!
3.6%
!
4.2%
!
5.1% of the
taxable amount of distribution.
Additional amount to be withheld per distribution $
2
! I hereby elect to terminate my prior election for voluntary Arizona income tax withholding from my annuity or pension payments as
authorized by ARS §43-404.
Annuitant’s Request for
Voluntary Arizona Income Tax Withholding
GENERAL INSTRUCTIONS
Who May Use Form A-4P
A person who receives an annuity or pension may use this form to
elect voluntary Arizona income tax withholding. Arizona withholding is
a percentage of the taxable amount of distribution in Box 2a of federal
Form 1099-R. Therefore, you may elect voluntary Arizona income
tax withholding at the applicable percentage rates and designate an
additional amount to be withheld.
“Annuity” means any amount paid to an individual as a pension or
annuity, but only to the extent that the amount is includible in the Arizona
gross income of that individual.
You may NOT elect to have Arizona income tax withheld from
nonperiodic payments, lump sum distributions, or individual retirement
account distributions, that do not meet the defi nition of annuity listed
above.
You also may NOT elect to have Arizona income tax withheld from
Social Security pensions, Veteran’s Administration annuities, or
Railroad Retirement pensions.
Where to Send Form A-4P
Send Form A-4P to the payor of your annuity or pension. Do not send
Form A-4P to the Arizona Department of Revenue.
Duration of Voluntary Arizona Withholding Election
The payor of your pension or annuity will withhold Arizona income tax
from your payments until you notify the payor to terminate Arizona
withholding.
How to Terminate a Voluntary Arizona Withholding Election
You may terminate your voluntary Arizona withholding election at any
time. You may use Form A-4P to terminate Arizona withholding or
you may send a written notice to the payor of your pension or annuity
requesting termination of withholding.
Statement of Income Tax Withheld
The payor of your pension or annuity will provide you with a form that
lists the total amount of your pension or annuity payments and the total
amount of Arizona income tax withheld from these payments for the
calendar year 2012. The payor of your pension or annuity will provide
this form to you in early 2013.
ARIZONA FORM
A-4P
I certify that I have made the percentage election marked above.
SIGNATURE DATE
ADOR 10122 (11)