Arizona Form                                  Annuitant’s Request for 
               A-4P                                 Voluntary Arizona Income Tax Withholding                                2021

 Type or print your Full Name                                                                     Your Social Security Number

 Home Address – number and street or rural route                                                  Annuity Contract Claim or I.D. Number

 City or Town                                                               State ZIP Code        Telephone Number (with area code)

Check either box 1 or box 2:
    1I elect to have Arizona income taxes withheld from my annuity or pension payments as authorized by A.R.S. § 43-404.  
        Withhold from the taxable amount of distribution 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 anextra          amount to be withheld per distribution ......................... $ 

    2I elect to terminate my prior election for voluntary Arizona income tax withholding from my annuity or pension payments 
        as authorized by A.R.S. § 43-404.

I certify that I have made the election marked above.

SIGNATURE DATE

                                                      General Instructions

Who May Use Form A-4P                                                        Where to Mail Form A-4P
You may use this form to request Arizona income tax withholding if you       Mail Form A-4P to the payor of your annuity or pension. Do not mail 
receive regularly scheduled payments from pensions or annuities that         Form A-4P to the Arizona Department of Revenue.
are included in your Arizona gross income from any of the following: 
                                                                             Duration of Voluntary Arizona Withholding Election
  •  Retired or retainer pay for service in the military or naval forces of  The payor of your pension or annuity will withhold Arizona income tax 
 the United States,                                                          from your payments until you notify the payor to change or terminate 
  •  Payments received under the United States civil service retirement      Arizona withholding.
 system from the United States government service retirement and 
                                                                             How to Terminate a Voluntary 
 disability fund,
                                                                             Arizona Withholding Election
 • Pensions,                                                                 You may terminate your voluntary Arizona withholding election at any 
  •  Traditional Individual Retirement Accounts, or                          time. You may use Form A-4P to terminate Arizona withholding or 
  •  Any other annuity.                                                      you may send a written notice to the payor of your pension or annuity 
                                                                             requesting termination of withholding.
You may NOT elect to have Arizona income tax withheld from the 
following:                                                                   Statement of Income Tax Withheld
  • Any payments NOT received at regular intervals (non-periodic             The payor of your pension or annuity will provide you with a statement 
 payments),                                                                  listing the total amount of your pension or annuity payments and the 
                                                                             total amount of Arizona income tax withheld from these payments for 
  • Lump sum distributions,                                                  the calendar year 2021. You will receive this statement from the payor 
  • Roth Individual Retirement Account distributions,                        of your pension or annuity early in 2022
  • Veteran’s Administration annuities, or
  • Railroad Retirement pensions.

ADOR 10122 (20)