Mail this form to the charitable organization or school.
Please do not mail this form to the Arizona Department of Revenue.
Payment for:
1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
EMPLOYER INFORMATION
Employer’s Name Date Payment is Made
M M D D Y Y Y Y
Employer’s Address – Number and street or PO Box Employer’s City, State and ZIP Code
CHARITABLE ORGANIZATION, SCHOOL TUITION ORGANIZATION, OR PUBLIC SCHOOL
Entity Name
Entity Address – Number and street or PO Box
Entity City, State and ZIP Code
Enclosed is a check in the amount of $__________________ as a contribution made by our employees listed below.
These employees elected to contribute to your organization using reduced withholding donations. Please issue a receipt
to each employee for the amount of his or her contribution.
EMPLOYEE CONTRIBUTIONS
Employee Name
Address
City
State
ZIP
Code
Phone Number
(with area code)
Contribution
$
$
$
$
$
Total $
Check this box if additional schedules are included. Enter the total from additional schedules $
Total Contributions $
Please contact me if you have any questions.
Sincerely,
SIGNATURE OF PAYROLL DEPARTMENT REPRESENTATIVE DATE
PRINT NAME TITLE
COMPANY NAME PHONE NUMBER (with area code)
E-MAIL ADDRESS
ADOR 10762 (19)
PLEASE DO NOT MAIL THIS FORM TO THE ARIZONA DEPARTMENT OF REVENUE.
Arizona Form
A1-QTC
Quarterly Payment of
Reduced Withholding for Tax Credits
2020
