Arizona Form               Arizona Withholding Reconciliation Return 
               A1-R                                     FOR FORM A1-QRT                                                                                   2020
Complete this form only if you file Form A1-QRT. Arizona Form A1-R is an information return.  Do not submit any liability owed 
or try to claim refunds with this return. To submit additional liability or claim a refund, file amended quarterly withholding tax Form(s) 
A1-QRT.  Form A1-R is due on or before January 31, 2021. Do NOT submit more than one A1-R per EIN per year.

Part 1   Taxpayer Information
Name                                                                                                                             Employer Identification Number (EIN)

Number and street or PO Box                                                                                                      REVENUE USE ONLY.  DO NOT MARK IN THIS AREA.
                                                                                                                                      88                             89 x
City or town, state and ZIP Code

Business telephone number (with area code)

Check box if:  A  Amended Return  B  Address Change
C  Check this box if return is an early-filed return for calendar year 2021 due to an account  
   cancellation during Calendar Year 2021.
   Check this box if cancellation was due to a merger or acquisition and the surviving employer                                      81 PM            66 RCVD
D 
   is filing Forms W-2.
E  Check this box if this form is being filed by the surviving employer and the amount on  
   line 10 is less than the amount on line 1 because the difference was remitted by the 
   predecessor employer. Also enter the following:
   Predecessor Employer Name ...................................................... 
   Predecessor Employer EIN.......................................................... 

Part 2   Federal Transmittal Information
 1  Total Arizona Tax Withheld per federal Forms W-2, W-2c, W-2G and 1099 for 2020 .............................                                     1
 2  Total Arizona wages paid to employees for 2020 ...................................................................................               2
 3  Total number of employees paid Arizona wages in 2020 ........................................................................                    3
 4  Total number of federal Forms W-2, W-2c, W-2G, and 1099 submitted to the department ....................                                         4
 5  Information Return Penalty ..................................................................................................................... 5               00
Part 3   Annual Summary of Amounts Reported on 2020 Arizona Forms A1-QRT
                                                                                                                                 Liability Reported
 6  First Quarter ............................................................................................................ 6
 7  Second Quarter .......................................................................................................     7
 8  Third Quarter ...........................................................................................................  8
 9  Fourth Quarter .........................................................................................................   9
 10  Total Annual Withholding Reported ........................................................................                10
Part 4   Explain Why an Amended Form A1-R is Being Filed (include additional sheet, if necessary)

               Under penalties of perjury, I declare that I have examined this return and to the best of my knowledge and belief, it is a true, complete 
  Declaration
               and correct return.
  Please 
  Sign 
  Here         TAXPAYER'S SIGNATURE                                                   DATE                                             BUSINESS TELEPHONE NUMBER

  Paid         PAID PREPARER’S SIGNATURE                                                                                         DATE       PAID PREPARER’S PTIN
  Preparer’s 
  Use          FIRM’S NAME (OR PAID PREPARER’S NAME, IF SELF-EMPLOYED)                                                                      FIRM’S EIN
  Only
               FIRM’S STREET ADDRESS                                                                                                        FIRM’S TELEPHONE NUMBER

               CITY                                                                                                              STATE      ZIP CODE
       Mail return to:  Arizona Department of Revenue, PO Box 29009, Phoenix, AZ  85038-9009
ADOR 10619 (20)