Mail this form to the charitable organization or school.
Please do not mail this form to the Arizona Department of Revenue.
1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
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 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.
(with area code)
Check this box if additional schedules are included. Enter the total from additional schedules $
Total Contributions $
Please contact me if you have any questions.
SIGNATURE OF PAYROLL DEPARTMENT REPRESENTATIVE DATE
PRINT NAME TITLE
COMPANY NAME PHONE NUMBER (with area code)
ADOR 10762 (19)
PLEASE DO NOT MAIL THIS FORM TO THE ARIZONA DEPARTMENT OF REVENUE.
Quarterly Payment of
Reduced Withholding for Tax Credits