Arizona Form                     Voluntary Withholding Request for 
               A-4V            Arizona Resident Employed Outside of Arizona                                         2021

 Type or print your Full Name                                                                            Your Social Security Number

 Home Address – number and street or rural route

 City or Town                                                                                      State ZIP Code

Check either box 1 or box 2:
    1I am an Arizona resident employed outside of Arizona.  I elect to have Arizona income taxes withheld from my 
        compensation paid for services performed outside of Arizona for my employer as authorized by A.R.S. § 43‑408.  
        Withhold from gross taxable wages at the percentage checked (check only one percentage):
         0.8%         1.3%    1.8%                 2.7%                       3.6%                   4.2%   5.1%

         Check this box and enter an extra amount to be withheld per paycheck ........................... $ 

    2I am an Arizona resident employed outside of Arizona.  I elect to terminate my prior election for voluntary Arizona income 
        tax withholding from my compensation paid for services performed outside of Arizona for my employer.

I certify that I have made the election marked above.

EMPLOYEE’S SIGNATURE                                                                                     DATE

                                                General Instructions

Who May Use Form A-4V                                                    What are my “Gross Taxable Wages”?
Arizona Form A‑4V is for Arizona resident employees who are performing   For withholding purposes, “gross taxable wages” are the wages from 
work outside of Arizona.  Use this form to request that your employer    each paycheck that will generally be in box 1 of your federal Form W‑2. 
withhold Arizona income taxes from your wages for work done outside      It is your gross wages less any pretax deductions, such as your share of 
of Arizona.  This amount is applied to your Arizona income tax due when  health insurance premiums.
you file your return.  Your employer is not required by statute to grant 
your request.                                                            What Should I do With Form A-4V?
If your employer agrees to withhold Arizona income tax from your         Complete this form to request that your employer withhold Arizona 
wages, Arizona withholding is a percentage of your gross taxable wages   income tax from your wages and elect an Arizona withholding percentage 
of every paycheck.  You may also have your employer withhold an extra    and any additional amount to be withheld from each paycheck.  Give 
amount from each paycheck.                                               your completed form to your employer.

                                                Employer Certification

                                                                         , the employer of an Arizona resident,
           (NAME OF EMPLOYER – COMPANY OR INDIVIDUAL)

                                                                         , whose compensation is for services performed outside of Arizona,
                              (EMPLOYEE’S NAME)
has agreed to withhold Arizona income taxes from the employee’s compensation as authorized by A.R.S. § 43‑408.  As stated in A.R.S. § 43‑408(B), 
the employer understands and agrees that the employer and the employee are subject to the provisions of Chapter 4 of Title 43 of the Arizona Revised 
Statutes, as if the employer were required to withhold Arizona income taxes from such compensation.

SIGNATURE OF OFFICER, SOLE PROPRIETOR, OR AGENT                            TITLE                                   DATE
ADOR 10372 (20)