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Arizona Statement of Exemption
Extracted from PDF file 2023-arizona-form-10834.pdf, last modified January 2010Statement of Exemption
Arizona Department of Revenue STATEMENT OF EXEMPTIONS 2024 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 (1/24) Print Tables for Figuring Amount Exempt from Levy on Wages, Salary, and Other Income (Forms 668-W) 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 2024 Filing Status: Single Filing Status: Married Filing Joint Return (and Qualifying Widow(er)s) Number of Dependents Claimed on Statement Pay Period 0 1 2 3 4 5 More Than 5 Pay Period Number of Dependents Claimed on Statement 0 2 3 4 5 More Than 5 Daily 112.31 131.54 150.77 170.00 189.23 208.46 280.77 plus 96.15 for each dependent Weekly 561.54 657.69 753.84 849.99 946.14 1042.29 561.54 plus 96.15 for each dependent 1523.09 561.54 plus 192.31 for each dependent Biweekly 1123.08 1315.39 1507.70 1700.01 1892.32 2084.63 1123.08 plus 192.31 for each dependent 1441.65 1649.98 608.33 plus 208.33 for each dependent Semimonthly 1216.67 1425.00 1633.33 1841.66 2049.99 2258.32 1216.67 plus 208.33 for each dependent 2883.35 3300.02 1216.67 plus 416.67 for Monthly each dependent 2433.33 2850.00 3266.67 3683.34 4100.01 4516.68 2433.33 plus 416.67 for each dependent Daily 56.15 75.38 94.61 113.84 133.07 152.30 Weekly 280.77 376.92 473.07 569.22 665.37 761.52 Biweekly 561.54 753.85 946.16 1138.47 1330.78 Semimonthly 608.33 816.66 1024.99 1233.32 Monthly 1216.67 1633.34 2050.01 2466.68 Filing Status: Head of Household Filing Status: Married Filing Separate Return Number of Dependents Claimed on Statement 0 1 2 3 4 5 84.23 103.46 122.69 141.92 161.15 180.38 84.23 plus 19.23 for each dependent Weekly 421.15 517.30 613.45 709.60 805.75 901.90 Biweekly 842.31 1034.62 1226.93 1419.24 1611.55 Semimonthly 912.50 1120.83 1329.16 1537.49 Monthly 1825.00 2241.67 2658.34 3075.01 Daily 1 112.31 plus 19.23 for each dependent 56.15 plus 19.23 for each dependent Pay Period 1-2024 More Than 5 Pay Period Number of Dependents Claimed on Statement 0 1 2 3 4 5 Daily 56.15 75.38 94.61 113.84 133.07 152.30 56.15 plus 19.23 for each dependent 421.15 plus 96.15 for each dependent Weekly 280.77 376.92 473.07 569.22 665.37 761.52 280.77 plus 96.15 for each dependent 1803.86 842.31 plus 192.31 for each dependent Biweekly 561.54 753.85 946.16 1138.47 1330.78 1523.09 561.54 plus 192.31 for each dependent 1745.82 1954.15 912.50 plus 208.33 for each dependent Semimonthly 608.33 816.66 1024.99 1233.32 1441.65 1649.98 608.33 plus 208.33 for each dependent 3491.68 3908.35 1825.00 plus 416.67 for Monthly each dependent 1216.67 1633.34 2050.01 2466.68 2883.35 3300.02 1216.67 plus 416.67 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 isexempt each pay period from a levy on wages, Filing Status * Single or Head of Household 1 7.50 37.50 2 15.00 75.00 1 5.96 29.81 2 11.92 3 17.88 4 23.85 119.23 Any Other Filing Status salary, and other income. Additional Exempt Amount Daily Semi-monthly Monthly 1. A single taxpayer who is paid weekly and claims three dependents has $569.22 exempt from levy. 75.00 81.25 162.50 2. If the taxpayer in number 1 is over 65 and writes 1 in the ADDITIONAL STANDARD DEDUCTION 150.00 162.50 325.00 59.62 64.58 129.17 59.62 119.23 129.17 258.33 89.42 178.85 193.75 387.50 4. if the taxpayer in number 3 is over 65 and has a spouse who is blind, this taxpayer should write 238.46 258.33 516.67 2 in the ADDITIONAL STANDARD DEDUCTION space on Parts 3,4, and 5 of the levy. If so, Weekly Biweekly www.irs.gov exempt from levy. $1,626.93 is exempt from this levy ($1,507.70 plus $119.23). * ADDITIONAL STANDARD DEDUCTION claimed on Parts 3,4, and 5 of levy. Publication 1494 (Rev. 1-2024) space on Parts 3, 4, & 5 of the levy, $606.72 is exempt from this levy ($569.22 plus $37.50). 3. A taxpayer who is married, files jointly, is paid bi-weekly, and claims two dependents has $1,507.70 Catalog Number 11439T Department of Treasury -- Internal Revenue Service
Statement of Exemptions
More about the Arizona Form 10834 Individual Income Tax TY 2023
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 2024, so this is the latest version of Form 10834, fully updated for tax year 2023. You can download or print current or past-year PDFs of Form 10834 directly from TaxFormFinder. You can print other Arizona tax forms here.
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 |
| Form 140 Instructions | Income Tax Instruction Packet |
| Form 140A | Resident Personal Income Tax (Short) Package |
| Form 204 | Application for Filing Extension |
| Form 321 | Credit for Contributions to Qualifying Charitable Organizations |
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 2024.
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 two 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:
2023 Form 10834
Statement of Exemptions
2022 Form 10834
Statement of Exemptions
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