Form # 300
Revised 8/2016
1400 West Third, Little Rock, AR 72201
Phone (501) 682-1517 or (800) 666-2877
Fax (501) 682-2359
Website - www.artrs.gov
Federal and State Tax Election Form
Payee Type: Member Survivor Beneficiary QDRO Recipient ▪ Member's SSN:________________
Member Information
Payee's Name________________________________________________SSN________________________________
Mailing Address___________________________________________________________________________________
City _______________________________ State ______________________________ Zip ____________________
Telephone Number (____) ______________________ E-mail Address ______________________________________
(FOR COMPLETE INSTRUCTIONS, REFER TO IRS FORM W-4P OR CALL YOUR TAX PREPARER.)
1(a). q Do not withhold any Federal Income Tax. CAUTION: There are penalties for not paying enough
Federal Income Tax during the year either through withholding or estimated tax payments.
1(b). q Withhold Federal Income Tax based on the following:
___ For yourself
___ For your spouse
___ Number of children or other dependents
___ Head of Household (enter one if you file Head of Household)
___ Child tax credit
___ TOTAL EXEMPTIONS (add lines above, enter zero for no exemptions)
Please check filing status: q Single q Married q Married but withhold at higher single rate
q Withhold an additional $________ per month for Federal Income Tax.
q Withhold set amount $________ per month for Federal Income Tax.
(FOR COMPLETE INSTRUCTIONS, REFER TO STATE OF ARKANSAS FORM AR4P OR CALL YOUR TAX PREPARER.)
2(a). q Do not withhold any Arkansas State Income Tax. CAUTION: There are penalties for not paying enough
Arkansas State Income Tax during the year either through withholding or estimated tax payments.
2(b). q Withhold Arkansas State Income Tax based on the following:
___ Single and you claim yourself
___ Married and you claim yourself and your spouse
___ Head of Household
___ Number of children or dependents
___ TOTAL EXEMPTIONS (add lines above, enter zero for no exemptions)
Please check filing status: q Single q Married
q Withhold an additional $________ per month for Arkansas State Income Tax.
q Withhold a set amount $________ per month for Arkansas State Income Tax.
Member's Signature _________________________________________ Date____________________
FEDERAL INCOME TAX
STATE INCOME TAX
