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Arizona Statement of Exemption
, or request a six-month extension here .Extracted from PDF file 2024-arizona-form-10834.pdf, last modified January 2010Statement of Exemption
Arizona Department of Revenue STATEMENT OF EXEMPTIONS 2025 PO BOX 29070 • PHOENIX, AZ 85038-9070 EMPLOYEE EMPLOYER Employee Full Name Business Name, “doing business as” Address – number and street Address – number and street City, Town or Post Office State SSN ZIP Code City, Town or Post Office State ZIP Code Phone Number To: Employer Under the provisions of A.R.S. § 42-1204, the department allows a certain amount to be exempted from levy. Before such an exemption is granted, the following statement must be completed and signed by the person claiming the exemption. If the statement is not completed by the employee, the exemption status will default to “single — zero exemption”. Please return the executed original using the enclosed envelope. See instructions below and on reverse. To: Employee The following statement must be completed and signed in order to claim an exemption from levy. If the statement is not completed by you, your exemption status will default to “single — zero exemption”. A “Notice of Levy on Wages, Salary, and other Income” was served on my income. To assist in figuring the amount of my income that is exempt from the levy, I certify that I am entitled to the exemptions below. Taxpayer: Additional Check if over 65 years old. Check if blind Deductions Taxpayer’s Spouse: Additional Check if over 65 years old. Check if blind Deductions I certify that I can claim the people named below as personal exemptions on my income tax return. No one listed is my minor child to whom (as required by court or administrative order) I make support payments that are already exempt from levy. I understand that the information I have provided may be verified. Under penalties of law, I declare that this statement of exemptions and filing status is true. Dependent’s Name (last, first, initial) Relationship 1 2 3 4 5 6 Signature Date INSTRUCTIONS TO COMPUTE AMOUNT EXEMPT FROM LEVY To compute the amount exempt from levy, add the total of names entered above, including yours and your spouse’s, and then, in Table A. on the reverse, find the filing status which matches your current income tax filing status. Using that table, find the number of exemptions and the frequency of your paydays, and use that amount as your exemption unless you and / or your spouse are over age 65 and / or blind. If so, you may claim an additional exemption. To compute that additional exemption, Use Table B on the reverse, and match your filing status, your number of additional deductions checked above, and the frequency of your payday. Add that amount to the amount computed in Table A to get your total exemption. See reverse for examples. Note: The amount exempt from levy may change annually. If it does and this levy remains in force next year, filing a new Statement of Exemptions will allow your employer to use the new year’s exemption table. To obtain a new form, phone the contact number on the contact number on the face of the levy form. ADOR 10834 (1/25) Print 1. Tables for Figuring Amount Exempt from Levy on Wages, Salary, and Other Income (Forms 668-W(ACS) and 668-W(ICS)) The tables below show the amount of an individual's income (take home pay) that is exempt from a notice of levy used to collect delinquent tax in 2025. Filing Status: Single Pay Period Filing Status: Married Filing Joint Return (and Qualifying Widow(er)s) Number of Dependents Claimed on Statement 0 1 2 3 4 5 Daily 57.69 77.31 96.93 116.55 136.17 155.79 57.69 plus 19.62 for each dependent Weekly 288.46 386.54 484.62 582.70 680.78 778.86 Biweekly 576.92 773.07 969.22 1165.37 1361.52 Semimonthly 625.00 837.50 1050.00 1262.50 Monthly 1250.00 1675.00 2100.00 2525.00 More Than 5 Number of Dependents Claimed on Statement Pay Period 0 1 2 3 4 5 Daily 115.38 135.00 154.62 174.24 193.86 213.48 115.38 plus 19.62 for each dependent 288.46 plus 98.08 for each dependent Weekly 576.92 675.00 773.08 871.16 969.24 1067.32 576.92 plus 98.08 for each dependent 1557.67 576.92 plus 196.15 for each dependent Biweekly 1153.85 1350.00 1546.15 1742.30 1938.45 2134.60 1153.85 plus 196.15 for each dependent 1475.00 1687.50 625.00 plus 212.50 for each dependent Semimonthly 1250.00 1462.50 1675.00 1887.50 2100.00 2312.50 1250.00 plus 212.50 for each dependent 2950.00 3375.00 1250.00 plus 425.00 for Monthly each dependent 2500.00 2925.00 3350.00 3775.00 4200.00 4625.00 2500.00 plus 425.00 for each dependent Number of Dependents Claimed on Statement 0 1 2 3 4 5 86.54 106.16 125.78 145.40 165.02 184.64 86.54 plus 19.62 for each dependent Weekly 432.69 530.77 628.85 726.93 825.01 923.09 Biweekly 865.38 1061.53 1257.68 1453.83 1649.98 Semimonthly 937.50 1150.00 1362.50 1575.00 Monthly 1875.00 2300.00 2725.00 3150.00 Daily More Than 5 Filing Status: Married Filing Separate Return Filing Status: Head of Household Pay Period 2025 More Than 5 Number of Dependents Claimed on Statement Pay Period 0 1 2 3 4 5 Daily 57.69 77.31 96.93 116.55 136.17 155.79 57.69 plus 19.62 for each dependent 432.69 plus 98.08 for each dependent Weekly 288.46 386.54 484.62 582.70 680.78 778.86 288.46 plus 98.08 for each dependent 1846.13 865.38 plus 196.15 for each dependent Biweekly 576.92 773.07 969.22 1165.37 1361.52 1557.67 576.92 plus 196.15 for each dependent 1787.50 2000.00 937.50 plus 212.50 for each dependent Semimonthly 625.00 837.50 1050.00 1262.50 1475.00 1687.50 625.00 plus 212.50 for each dependent 3575.00 4000.00 1875.00 plus 425.00 for Monthly each dependent 1250.00 1675.00 2100.00 2525.00 2950.00 3375.00 1250.00 plus 425.00 for each dependent 2. Table for Figuring Additional Exempt Amount for Taxpayers More Than 5 Examples at Least 65 Years Old and/or Blind These tables show the amount of take home pay that is exempt each pay period from a levy on wages, Filing Status * Single or Head of Household Any Other Filing Status salary, and other income. Additional Exempt Amount Daily Weekly Biweekly Semi-monthly Monthly 1. A single taxpayer who is paid weekly and claims three dependents has $582.70 exempt from levy. 1 7.69 38.46 76.92 83.33 166.67 2. If the taxpayer in number 1 is over 65 and writes 1 in the ADDITIONAL STANDARD DEDUCTION 2 15.38 76.92 153.85 166.67 333.33 1 6.15 30.77 61.54 66.67 133.33 2 12.31 61.54 123.08 133.33 266.67 3 18.46 92.31 184.62 200.00 400.00 4. if the taxpayer in number 3 is over 65 and has a spouse who is blind, this taxpayer should write 4 24.62 123.08 246.15 266.67 533.33 2 in the ADDITIONAL STANDARD DEDUCTION space on Parts 3,4, and 5 of the levy. If so, www.irs.gov 3. A taxpayer who is married, files jointly, is paid bi-weekly, and claims two dependents has $1,546.15 exempt from levy. $1,669.23 is exempt from this levy ($1,546.15 plus $123.08). * ADDITIONAL STANDARD DEDUCTION claimed on Parts 3,4, and 5 of levy. Publication 1494 (Rev. 1-2025) space on Parts 3, 4, & 5 of the levy, $621.16 is exempt from this levy ($582.70 plus $38.46). Catalog Number 11439T Department of Treasury -- Internal Revenue Service
Statement of Exemptions
More about the Arizona Form 10834 Individual Income Tax TY 2024
Use the form Statement of Exemption to declare the amount that the department allows to be exempted from your levy
We last updated the Statement of Exemption in February 2025, so this is the latest version of Form 10834, fully updated for tax year 2024. You can download or print current or past-year PDFs of Form 10834 directly from TaxFormFinder. You can print other Arizona tax forms here.
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TaxFormFinder has an additional 95 Arizona income tax forms that you may need, plus all federal income tax forms.
| Form Code | Form Name |
|---|---|
| Form 140 | Resident Personal Income Tax Return |
| Form A-4 | Employee’s Arizona Withholding Election |
| Form 140ES | Individual Estimated Tax Payment Booklet |
| Form 321 | Credit for Contributions to Qualifying Charitable Organizations |
| Form 140 Tax Tables | Form 140 Optional Tax Tables |
View all 96 Arizona Income Tax Forms
Form Sources:
Arizona usually releases forms for the current tax year between January and April. We last updated Arizona Form 10834 from the Department of Revenue in February 2025.
About the Individual Income Tax
The IRS and most states collect a personal income tax, which is paid throughout the year via tax withholding or estimated income tax payments.
Most taxpayers are required to file a yearly income tax return in April to both the Internal Revenue Service and their state's revenue department, which will result in either a tax refund of excess withheld income or a tax payment if the withholding does not cover the taxpayer's entire liability. Every taxpayer's situation is different - please consult a CPA or licensed tax preparer to ensure that you are filing the correct tax forms!
Historical Past-Year Versions of Arizona Form 10834
We have a total of three past-year versions of Form 10834 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:
2024 Form 10834
Statement of Exemptions
2023 Form 10834
Statement of Exemptions
2022 Form 10834
Statement of Exemptions
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