Who May Use Form A-4PYou 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:

• Retiredorretainerpayforserviceinthemilitaryornavalforcesofthe United States,

• PaymentsreceivedundertheUnitedStatescivilserviceretirementsystem from the United States government service retirement and disability fund,

• Pensions,

• TraditionalIndividualRetirementAccounts,or

• Anyotherannuity.

You may NOT elect to have Arizona income tax withheld from thefollowing:

• Any payments NOT received at regular intervals (non-periodicpayments),

• Lumpsumdistributions,

• RothIndividualRetirementAccountdistributions,

• Veteran’sAdministrationannuities,or

• RailroadRetirementpensions.

Where to Mail Form A-4PMailFormA-4P to thepayorofyourannuityorpension.DonotmailFormA-4PtotheArizonaDepartmentofRevenue.

Duration of Voluntary Arizona Withholding ElectionThepayorofyourpensionorannuitywillwithholdArizonaincometaxfrom your payments until you notify the payor to change or terminate Arizonawithholding.

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

Statement of Income Tax WithheldThepayorofyourpensionorannuitywillprovideyouwithastatementlisting the total amount of your pension or annuity payments and the total amount of Arizona income tax withheld from these payments for thecalendaryear2018.Youwillreceivethisstatementfromthepayorofyourpensionorannuityearlyin2019.

ADOR10122(17)

TypeorprintyourFullName YourSocialSecurityNumber

HomeAddress–numberandstreetorruralroute AnnuityContractClaimorI.D.Number

CityorTown State ZIPCode TelephoneNumber(withareacode)

Check either box 1 or box 2: 1 IelecttohaveArizonaincometaxeswithheldfrommyannuityorpensionpaymentsasauthorizedbyA.R.S.§43-404.

Withhold from the taxable amount of distribution at the percentage checked (check only one percentage):0.8% 1.3% 1.8% 2.7% 3.6% 4.2% 5.1%

Check this box and enter an extra amount to be withheld per distribution......................... $

2 IelecttoterminatemypriorelectionforvoluntaryArizonaincometaxwithholdingfrommyannuityorpensionpaymentsasauthorizedbyA.R.S.§43-404.

IcertifythatIhavemadetheelectionmarkedabove.

SIGNATURE DATE

General Instructions

Arizona Form

A-4PAnnuitant’s Request for

Voluntary Arizona Income Tax Withholding 2018