AR4ECSP

                                  STATE OF ARKANSAS
                    Employee’s Special Withholding Exemption Certificate

Print full name                   Social Security Number

Print home address                City                                                                    State          Zip

          :                       CHECK THE APPLICABLE BLOCK: 
Employee
File this form with        I am single and my gross income from all sources will not exceed $1 ,3 446.00. 
your employer 
to exempt your 
earnings from 
State income tax           I am married filing jointly with my spouse, have 1 or less dependents, and our combined gross 
withholding.               income from all sources will not exceed $2 ,2 675.00. 
Employer: 
Keep this 
certificate with           I am married filing jointly with my spouse, have 2 or more dependents, and our combined gross 
your records.              income from all sources will not exceed $2 ,7 291.00. 

                           I am unmarried filing Head of Household or a Qualifying Widow(er), have 1 or less dependents, and 
                           my gross income from all sources will not exceed $1 ,9 117.00. 

                           I am unmarried filing Head of Household or a Qualifying Widow(er), have 2 or more dependents, 
                           and my gross income from all sources will not exceed $2 ,2 789.00. 

I certify that the number of exemptions and dependents claimed on this certificate does not exceed the number to which I am entitled.

Signature:                                                                                                Date:

Page AR4ECSP (R 11/16/2022)