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General Instructions for Registering and Filing Withholding Tax Statements for the State of Arkansas - page 3 / 4

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AR4ER

STATE OF ARKANSAS

Withholding Registration

P. O. Box 8055, Little Rock, Arkansas 72203-8055 (Please read instructions on reverse side. Please type or print. Keep one copy for your records) ALL NEW ACCOUNTS FILE ON A MONTHLY BASIS - THERE IS NO QUARTERLY FILING

1

Type of Withholding (Check only one)

2.

Employer’s Federal Identification Number:

3.

Name of Business: (Trade Name)

4.

Business Location: (Physical Address)

Wages

Pension

Pass Through Entity

____

____

_____

____

____

____

____

____

____

(

)

Telephone Number

_______________________________________________________________________ Street

_______________________________________________________________________

_______________________________________________________________________ City State Zip

5.

Mailing or Care of Address:

__________________________________________________________________________ In Care of

__________________________________________________________________________ Street

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

__________________________________________________________________________ City State Zip

6.

Name of Owner or Responsible Party:

Social Security Number:

7.

Address of Owner/Responsible Party:

a.

b.

c.

(

)

Telephone Number

____

____

____

____

____

____

_____ _____ _____

__________________________________________________________________________ Street

__________________________________________________________________________

__________________________________________________________________________ City State Zip

8.

Date Arkansas Withholding was Started and/or Required:

9.

Principle Business Activity: (See Instructions)

10.

Type of Organization:

11.

County - Arkansas:

12.

Signature of Owner or Responsible Party

mm/dd/yy

1. Sole Proprietorship

2. Partnership

3. Domestic Corp. / Domestic LLC

4. Foreign Corp. / Foreign LLC

__________________________________________________________________________

Signature

Date

13.

Federal Business Code:

FOR DEPT.

Exam

USE ONLY

Code

AR4ER (R 10/04/06)

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