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 ,3 054.00. 
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 ,2 015.00. 
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 ,6 496.00. 

                           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 $18,560.00. 

                           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 ,2 125.00. 

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 11/17/2021)