ADOR 10125 (20)
Type or print your Full Name Your Social Security Number
Home Address – number and street or rural route
City or Town State ZIP Code
Arizona Form
WEC
Employee Withholding Exemption Certificate
2021
Part 1
Native American Withholding Exemption
I request to have no Arizona income tax withheld from my wages because I declare that:
1
I am a Native American — Enter your Tribal Census Number: .
2
I reside on the Indian Reservation.
3
I am an enrolled member of the tribe for which that reservation was established.
4
All my services as an employee of are performed within
the boundaries of the reservation named above.
Part 2
Nonresident Military Spouse Withholding Exemption
I request to have no Arizona income tax withheld from my wages because I declare that:
1
I am the spouse of an active duty servicemember.
2
Both my spouse and I are Arizona nonresidents. My state of residence is
and my military spouse's state of residence is (must be the same state).
3
My active duty military spouse is in Arizona in compliance with military orders.
4
I am present in Arizona solely to be with my military spouse.
My Military ID Number is: Date Issued:
M M D D Y Y Y Y
You must include a copy of your military spouse ID and your spouse's last Leave and Earnings Statement (LES).
Part 3
Nonresident Withholding Exemption
I request to have no Arizona income tax withheld from my wages because I declare that:
1
I am an Arizona nonresident, and I am a resident of:
California Indiana Oregon Virginia
2
I am allowed a tax credit against my Arizona taxes for taxes paid to the state checked above.
Part 4
Termination
I am notifying my employer that I no longer qualify for the previously-claimed withholding exemption. By checking this
box, I terminate my exemption.
Part 5
Signatures
EMPLOYEE EMPLOYER
Under penalty of perjury, I certify that I am entitled to the exemption from
withholding as claimed above.
EMPLOYEE'S SIGNATURE DATE
I have reviewed all documentation required to be submitted with this request
and confirm that if the employee is claiming the exemption under Part 1, that
the employee's place of employment is located on the reservation named
in Part 1.
EMPLOYER'S SIGNATURE DATE
Give the completed form and any required documentation to your employer. Keep the completed form and any documentation for your records. Please
do not mail this form to the department unless you are asked to do so.
