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

Request for Arizona Voluntary Income Tax Withholding on
Retirement Income

2025

	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 or retirement account distributions
as authorized by A.R.S. § 43‑404. Withhold from the taxable amount of payment or 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 payment or distribution....... 	$	
 2	 I elect to terminate my prior election for voluntary Arizona income tax withholding from my annuity or pension payments
or retirement account distribution as authorized by A.R.S. § 43‑404.
I certify that I have made the election marked above.
	

	



SIGNATURE	DATE

General Instructions
Who May Use Form A-4P
You may use this form to request Arizona income tax be withheld if
you receive a payment from a pension, annuity, or a distribution from a
retirement account.
You may request to have Arizona income tax withheld from your
pension, annuity, or distribution, but only to the extent your payment
or distribution is includable in your Arizona gross income.
You may not request Arizona income tax be withheld from the payment
of any pension, annuity, or distribution you receive that is not includable
in your Arizona gross income, such as a Roth IRA.

For purposes of this form:
“Pension” means:
	 •	 A defined benefit plan authorized under the Internal Revenue Code
(IRC) that is paid to an individual.
	 •	 Periodic, fixed amount retirement payments made by the United
States Military, the United States Civil Service or a state or local
government or a private employer to former employees and
surviving spouses of former employees for prior services performed.
“Annuity” means:
	 •	 An employee annuity plan authorized under the IRC and paid to an
individual.
	 •	 Specified income payable at stated intervals to an individual for a
fixed or contingent period, often for the life of the individual.

“Retirement account” includes:
	 •	 A qualified retirement plan under Sections 401, 403, and 457 of the
IRC.
	 •	 An individual retirement account under Section 408 of the IRC,
including a simplified employee pension fund under IRC 408(k) and
a simple retirement account under IRC 408(p).
ADOR 10122 (24)

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How do I initiate or adjust Arizona
voluntary withholding?
You may initiate or adjust Arizona voluntary withholding by executing
and providing Form A-4P or its electronic equivalent to the payor of
your annuity or pension, or your retirement account administrator. Do
not mail or email Form A-4P to the Arizona Department of Revenue.

Duration of Voluntary Arizona Withholding Election
The payor of your pension or annuity or retirement account administrator
will withhold Arizona income tax from your payments or retirement
distributions until you notify the payor or retirement administrator to
change or terminate Arizona withholding.

How to Terminate a Voluntary
Arizona Withholding Election
You may terminate your voluntary Arizona withholding election at any
time. A request to terminate Arizona voluntary withholding should be
provided to the payor of the pension or annuity or to the retirement
administrator in writing by either paper or electronic means on either
Form A-4P or its electronic equivalent.

Statement of Income Tax Withheld
The payor of your pension or annuity or your retirement account
administrator will provide you with a statement listing the total amount
of your pension or annuity payments or retirement account distributions
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 or retirement account
administrator early in 2025.