Arizona Annuitant's Request for Voluntary Arizona Income Tax Withholding

Annuitant's Request for Voluntary Arizona Income Tax Withholding
Arizona Form A-4P
Arizona Form

A-4P

Annuitant’s Request for
Voluntary Arizona Income Tax Withholding

2024

	Type or print your Full Name			

Your Social Security Number

	Home Address – number and street or rural route			

Annuity Contract Claim or I.D. Number

	City or Town	

Telephone Number (with area code)

State	

ZIP Code	

Check either box 1 or box 2:
 1	 I elect to have Arizona income taxes withheld from my annuity or pension payments as authorized by A.R.S. § 43‑404.
Withhold from the taxable amount of distribution at the percentage checked (check only one percentage):
 0.5%	
 1.0%	
 1.5%	
 2.0%	
 2.5%	
 3.0%	
 3.5%

		  Check this box and enter an extra amount to be withheld per distribution.......................... 	$	
 2	 I elect to terminate my prior election for voluntary Arizona income tax withholding from my annuity or pension payments
as authorized by A.R.S. § 43‑404.

I certify that I have made the election marked above.
	

	



SIGNATURE	DATE

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General Instructions
Who May Use Form A-4P

Where to Mail Form A-4P

You may use this form to request Arizona income tax withholding if you
receive regularly scheduled payments from pensions or annuities that
are included in your Arizona gross income from any of the following:

Mail Form A-4P to the payor of your annuity or pension. Do not mail
Form A-4P to the Arizona Department of Revenue.

	 •	 Retired or retainer pay for service in the military or naval forces of
the United States,

The payor of your pension or annuity will withhold Arizona income tax
from your payments until you notify the payor to change or terminate
Arizona withholding.

	 •	 Payments received under the United States civil service retirement
system from the United States government service retirement and
disability fund,
	 •	Pensions,
	 •	 Traditional Individual Retirement Accounts, or
	 •	 Any other annuity.
You may NOT elect to have Arizona income tax withheld from the
following:
	 •	Any payments NOT received at regular intervals (non-periodic
payments),
	 •	 Lump sum distributions,
	 •	 Roth Individual Retirement Account distributions,
	 •	 Veteran’s Administration annuities, or
	 •	 Railroad Retirement pensions.

ADOR 10122 (23)

Duration of Voluntary Arizona Withholding Election

How to Terminate a Voluntary
Arizona Withholding Election
You may terminate your voluntary Arizona withholding election at any
time. You may use Form A-4P to terminate Arizona withholding or
you may send a written notice to the payor of your pension or annuity
requesting termination of withholding.

Statement of Income Tax Withheld
The payor of your pension or annuity will provide you with a statement
listing the total amount of your pension or annuity payments and the
total amount of Arizona income tax withheld from these payments for
the calendar year 2024. You will receive this statement from the payor
of your pension or annuity early in 2024