Arizona Employer Affidavit

Employer Affidavit
Employer Affidavit
ARIZONA DEPARTMENT OF REVENUE
EMPLOYER AFFIDAVIT

TO BE COMPLETED BY THE EMPLOYEE

I hereby certify that the Arizona Department of Revenue is authorized to release to my employer confidential information concerning
me for tax years 	

to verify my Arizona wages and withholding.

SIGNATURE		DATE		SIGNATURE		DATE

PRINT NAME

PRINT NAME

TO BE COMPLETED BY THE EMPLOYER
Date: 	
To: Arizona Department of Revenue
From:

Name of Business

Employer Identification Number (EIN)

Business Location Address

Telephone Number

City

RE:	

State

Calendar Year

Employment of:

ZIP Code

(Legal name of employee)

During calendar year I employed the person named above. My records show that the above-named employee submitted a
Social Security Number of 	
which I used for employment purposes.
For calendar year
this employee had:
Total wages earned:	

$

Total Arizona tax withheld:	

$

I DECLARE UNDER PENALTIES OF PERJURY THAT ALL THE INFORMATION I HAVE PROVIDED ABOVE
IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
Signature of Employer or Employer’s Authorized Agent	

Title

Print Name

STATE OF	

)

COUNTY OF	

)

Subscribed and sworn (or affirmed) before me this

, by:

PRINT NAME OF SIGNOR
(Notary Seal)

NOTARY PUBLIC
ADOR 11161 (6-23)

Name used on tax return
day of

,
20

FOR DOR USE ONLY

Identification number used on tax return

__ __ __ - __ __ - __ __ __ __
Please return to:
Arizona Department of Revenue
PO Box 29099
Phoenix, AZ 85038-9099
or
[email protected]