AR4PT-A                                 STATE OF ARKANSAS
                    Transmittal of Nonresident Member Withholding
 CLICK HERE TO CLEAR FORM               Exemption Affidavit

Name of Entity                                                          FEIN

Address                                                                 Name of Contact Person

City, State and ZIP                                                     Contact Person’s Telephone Number

Type of Media (check one)                      Diskette              CD     Paper

To assist us in processing your information accurately, please use this form as a cover for the transmittal of 
the diskette(s) or CD(s) containing the affidavit information or for the transmittal of the paper copies of Form(s) 
AR4PT.

Please label the diskette or CD with the name of the pass-through entity, the Federal Identification Number and 
the number of records. If your information resides on more than one diskette or CD, each must be labeled:
1 of ___, 2 of ___, etc.

Attach the diskette, CD or Form(s) AR4PT to this form and mail to the address below on or before the due date 
of the pass-through entity’s income tax return, including extensions.

For those taxpayers that have received a waiver from the filing of the nonresident member information by CD 
or diskette, copies of all Nonresident Member Withholding Exemption Affidavits (Form AR4PT) must be filed 
with this form and mailed to the address below on or before the due date of the pass-through entity’s income 
tax return, including extensions.

Note:  This form must not be included or attached to any other documents or tax forms being mailed 
        to the Arkansas Department of Finance and Administration. Please mail independently of other 
        report or form filings.

Mail to:            Individual Income Tax Section
                    Pass-Through Entity
                    Post Office Box 3628
                    Little Rock, AR  72203-3628

AR4PT-A (R 10/23/07)