Arizona Form                               Quarterly Payment of 
           A1-QTC                                Reduced Withholding for Tax Credits                              2021

               Mail this form to the charitable organization, school tuition organization, or public school.
                       Please do not mail this form to the Arizona Department of Revenue.

   Payment for:         1st Quarter                     2nd Quarter         3rd Quarter        4th Quarter

                                                       EMPLOYER INFORMATION
Employer’s Name                                           Date Payment is Made
                                                          M M D D Y Y Y Y
Employer’s Address – Number and street or PO Box          Employer’s City, State and ZIP Code

                    CHARITABLE ORGANIZATION, SCHOOL TUITION ORGANIZATION, OR PUBLIC SCHOOL
Entity Name

Entity Address – Number and street or PO Box

Entity City, State and ZIP Code

Enclosed is a check in the amount of $__________________as            a contribution made by our employees listed below.  
These employees elected to contribute to your organization using reduced withholding donations.  Please issue a receipt 
to each employee for the amount of his or her contribution.

                                                    EMPLOYEE CONTRIBUTIONS
                                                                                          ZIP    Phone Number           
   Employee Name                            Address                   City     State      Code   (with area code)     Contribution
                                                                                                                      $
                                                                                                                      $
                                                                                                                      $
                                                                                                                      $
                                                                                                                      $
                                                                                                           Total      $
  Check this box if additional schedules are included.                     Enter the total from additional schedules $
                                                                                               Total Contributions    $
Please contact me if you have any questions.

Sincerely,

SIGNATURE OF PAYROLL DEPARTMENT REPRESENTATIVE                              DATE

PRINT NAME                                                                  TITLE

COMPANY NAME                                                                PHONE NUMBER (with area code)

E-MAIL ADDRESS

                PLEASE DO NOT MAIL THIS FORM TO THE ARIZONA DEPARTMENT OF REVENUE.
ADOR 10762 (20)