Arkansas Form Ar4Pt – Fill Out and Use This PDF

STATE OF ARKANSAS		AR4PT
Nonresident Member Withholding
Exemption Afidavit
PART A: Pass-Through Entity Information
Name of Entity	FEIN
Address	Type of Pass-Through Entity
	S-Corporation	Trust
City, State, Zip	Partnership	Other
	Limited Liability Co.
PART B: Nonresident Member Information
Name of Member	SSN or FEIN
Address
City, State, Zip
PART C: Withholding Tax Exemption

I,______________________________________________, as a nonresident member of the above named

pass-through entity, request to be exempt from Arkansas income tax withholding per Arkansas Code Annotated 26-51-919(b)(1)(A) for tax year ______________________, and all subsequent years, until I notify theArkansas

Department of Finance and Administration of a change in this election (see Part D.)

By signing this afidavit I agree to be subject to the personal jurisdiction of the Arkansas Department of Finance and Administration in the courts of this state for the purpose of determining and collecting any Arkansas taxes, including estimated tax payments, together with any related interest and penalties.

I agree to timely ile appropriate income tax returns, or be included in the pass-through entity’s income tax return, and make payment of all Arkansas taxes as required by law.

If I fail to abide by the terms of this afidavit I understand that the Arkansas Department of Finance and Administration may revoke at any time the withholding exemption granted under Arkansas Code Annotated 26-51-919(c)(5)(B).

PART D: Withholding Tax Exemption Revocation

I,______________________________________________, as a nonresident member of the above named

pass-through entity, hereby revoke my previous withholding election dated_______________.

At this time, I request to be subject to income tax withholding on my share of distributed Arkansas income of the above named pass-through entity for tax year _______, and all subsequent years, until I notify theArkansas

Department of Finance and Administration of a change of this election.

PART E: Signature

____________________________________________________________	______________________
Signature of Nonresident Member	Date
Daytime Telephone Number __________________

AR4PT (R 10/29/09)

Instructions for Nonresident Member

Withholding Exemption Afidavit

Requirement to Make Withholding Payments

Arkansas Code Annotated 26-51-919(b)(1)(A) requires a pass-through entity to withhold income tax at the rate of 7% on each nonresident member’s share of distributed Arkansas income. A pass-through entity is not required to withhold income tax for any nonresident member who submits a Nonresident Member Withholding Exemption Afidavit (Form AR4PT).

Instructions for Nonresident Member

Any nonresident member receiving a distribution of Arkansas income from a pass-through entity may claim an exemption from

the withholding requirement by completing Parts A, B, C and E and submitting the completed afidavit to the pass-through

entity.

A nonresident member who has previously received an exemption from the withholding requirement may revoke such exemption by completing Parts A, B, D and E and submitting the completed afidavit to the pass-through entity.

If any of the information provided in Parts A or B changes, a new afidavit must be iled with the pass-through entity.

Instructions for Pass-through Entity

The pass-through entity must retain the original Nonresident Member Withholding Exemption Afidavits and provide copies to

the Arkansas Department of Finance and Administration (DFA) upon request. All pass-through entities must provide DFA on an annual basis with the name, address, and identiication number of all nonresident members for whom they have received a Nonresident Member Withholding Exemption Afidavit on an annual basis as described below:

a.Pass-through entities are required to ile the nonresident member afidavit information on a CD or diskette using a spreadsheet format (such as Excel), a database format (such as Access), or a Delimited Text File. Due to security

reasons, the information cannot be sent electronically at this time. All of the information shown in Parts A and B must be provided using the predeined record layouts. The predeined record layouts may be accessed on our website at www.arkansas.gov/dfa/income_tax/tax_wh_forms/.

b.Please ile the CD or diskette using transmittal Form AR4PT-A by the due date of the pass-through entity’s income tax return, including extensions, at the address below.

c.To obtain a waiver from iling on a CD or diskette, the pass-through entity must mail a request to the DFA at the address below and detail any hardship that would result if required to ile on a CD or diskette.

d.For those pass-through entities that are granted a waiver, copies of all Nonresident Member Withholding Exemption

Afidavits must be iled using transmittal Form AR4PT-A by the due date of the pass-through entity’s income tax return, including extensions, at the address below.

Mailing Address

Individual Income Tax Section

Pass-Through Entity

Post Ofice Box 3628

Little Rock, AR 72203-3628

AR4PT Instr (R 10/29/09)