Arizona Form                 Employer’s Election to 
               A1-E                        Not Withhold Arizona Taxes in December                 2021

 Name                                                                                Employer Identification Number

 Address – number and street or rural route

 City or Town                                                                  State ZIP Code

Number of Arizona employees:  

  Election is hereby made to not withhold Arizona taxes from compensation paid to employees during the month 
 of December 2021, and certification is made that all employees have been notified of this and given the option of 
 completing a new Arizona Form A-4 to change the withholding election for the rest of the year.

I certify that I am authorized to make and have made the election marked above.

SIGNATURE                                                   PHONE NUMBER (with area code)        DATE

                                            General Instructions

Purpose of Form A1-E                                      Deadline
Form A1-E is to be used by Arizona employers              Form A1-E must be filed and all employees notified by 
to elect to not withhold Arizona taxes from compensation  July 1, 2021.
paid to employees during December. If you make this 
                                                          Where to Mail Form A1-E
election, it applies to all employees.
                                                          Mail Form A1-E to:
Action Required
• Notify all your employees in writing, informing them of OFFICE OF ECONOMIC RESEARCH AND ANALYSIS
 your election to not withhold Arizona taxes from their   ARIZONA DEPARTMENT OF REVENUE 
 December 2021 wages and informing them that they         PO BOX 29099 
 can, if they wish, complete Arizona Form A-4 to adjust   PHOENIX, AZ  85038-9099
 their Arizona withholding election to compensate for the 
 change in their annual withholding amount.               Duration of this Election
• Complete Form A1-E and mail it by July 1, 2021.  You    This election is valid for December 2021 only.
 only need to submit one Form A1-E for all employees.

ADOR 10682 (20)