Arizona PACT Act Statement

PACT Act Statement
PACT Act StatementArizona Department of Revenue • Tobacco Tax

PACT Act Statement
(15 U.S.C. 376(a)(1))
Federal law requires filing of this form by any person who intends to sell, transport, or ship cigarettes or
smoking tobacco into Arizona (or who advertises or offers to do so) from outside the state, from Indian
country, or from within Arizona if passing through points outside the state or in Indian country. This form
must be filed before any such sale or transfer. The Arizona Department of Revenue will not consider this
statement properly filed unless all of the requested information is accurately and completely provided.

SELLER’S INFORMATION
Name of Seller

Trade Name (if applicable)

Principle Place of Business - Address

Phone Number (with area code)

City

State

Address of any other place of business

Phone Number (with area code)

City

State

Seller’s Email Address

Web Site Address

Zip Code

Zip Code

AUTHORIZED AGENT’S INFORMATION
(must meet requirements for statutory agents found in A.R.S. Title 10 or 29)
Name of Authorized Agent

Address

Phone Number (with area code)

City

State

Zip Code

PLEASE SIGN HERE

AZ
Under penalties of perjury, I/we declare that to the best of my/our knowledge and belief, the information in this statement
is true, correct and complete.

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PRINT YOUR NAME

TITLE

YOUR SIGNATURE

DATE

Please mail to: Arizona Department of Revenue, Tobacco Tax, 1600 West Monroe, Phoenix, AZ 85007
ADOR 11134 (7/10)

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Reset Agent

Extracted from PDF file 2023-arizona-form-11134.pdf, last modified October 2009

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More about the Arizona Form 11134 Individual Income Tax TY 2023

Arizona residents who qualify, complete this form to request to have no Arizona income tax withheld from their wages.

We last updated the PACT Act Statement in February 2024, so this is the latest version of Form 11134, fully updated for tax year 2023. You can download or print current or past-year PDFs of Form 11134 directly from TaxFormFinder. You can print other Arizona tax forms here.

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Other Arizona Individual Income Tax Forms:

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 Tax Return
Form 140 Instructions	Income Tax Instruction Packet
Form 140A	Resident Personal Income Tax (Short) Package Tax Return
Form 204	Application for Filing Extension Extension
Form 321	Credit for Contributions to Qualifying Charitable Organizations Tax Credit

Download all AZ tax forms 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 11134 from the Department of Revenue in February 2024.

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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 11134

We have a total of two past-year versions of Form 11134 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:

2023 Form 11134

PACT Act Statement

2022 Form 11134

PACT Act Statement

TaxFormFinder Disclaimer:

While we do our best to keep our list of Arizona Income Tax Forms up to date and complete, we cannot be held liable for errors or omissions. Is the form on this page out-of-date or not working? Please let us know and we will fix it ASAP.