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2006 AR941 COUPON DUE ON THE 15TH DAY OF THE MONTH FOLLOWING THE REPORTING PERIOD You must cut along the dotted line or the processing of your payment will be delayed. AR941M State of Arkansas Monthly Withholding Report FEIN 99-9999999 Period Covered mm/yyyy Due Date A FOR OFFICE USE ONLY B Name of Company Tax Withheld Address Adjustments Tax Paid City State Zip I declare under penalties of perjury that I have examined this return and to the best of my knowledge and belief it is a true correct and complete return. Signature Date 18110000000000000000000000020060 Phone Click Here to Print Document Click Here to Clear Voucher. INSTRUCTIONS PERIOD COVERED AND DUE DATE Enter the reporting period and due date for this coupon* You can only report one period per coupon* All new accounts are reported and paid on the 15th of the following month. There is no quarterly filing. ID NUMBER Enter your Federal Identification Number. TAX WITHHELD Enter the total amount of Arkansas Income Tax withheld for this monthly reporting period. ADJUSTMENTS Enter any adjustment to be deducted from the amount you will pay for this period. You must include a detailed explanation of any adjustment you list. AMOUNT PAID Enter the amount paid less any adjustments. MAKE YOUR CHECK OR MONEY ORDER PAYABLE TO Department of Finance and Administration MAIL TO Individual Income Tax Section Withholding Branch P. O. Box 9941 Little Rock Arkansas 72203-9941 ADDITIONAL INFORMATION To CHANGE YOUR ADDRESS or to CLOSE YOUR BUSINESS for Withholding purposes please complete and submit the appropriate forms. These forms can be found on our website at www. arkansas. gov/dfa or they will be mailed to you by contacting 501 682-7290. INSTRUCTIONS PERIOD COVERED AND DUE DATE Enter the reporting period and due date for this coupon* You can only report one period per coupon* All new accounts are reported and paid on the 15th of the following month. There is no quarterly filing. ID NUMBER Enter your Federal Identification Number. TAX WITHHELD Enter the total amount of Arkansas Income Tax withheld for this monthly reporting period. There is no quarterly filing. ID NUMBER Enter your Federal Identification Number. TAX WITHHELD Enter the total amount of Arkansas Income Tax withheld for this monthly reporting period. ADJUSTMENTS Enter any adjustment to be deducted from the amount you will pay for this period. You must include a detailed explanation of any adjustment you list. ADJUSTMENTS Enter any adjustment to be deducted from the amount you will pay for this period. You must include a detailed explanation of any adjustment you list. AMOUNT PAID Enter the amount paid less any adjustments. MAKE YOUR CHECK OR MONEY ORDER PAYABLE TO Department of Finance and Administration MAIL TO Individual Income Tax Section Withholding Branch P. AMOUNT PAID Enter the amount paid less any adjustments. MAKE YOUR CHECK OR MONEY ORDER PAYABLE TO Department of Finance and Administration MAIL TO Individual Income Tax Section Withholding Branch P. O. Box 9941 Little Rock Arkansas 72203-9941 ADDITIONAL INFORMATION To CHANGE YOUR ADDRESS or to CLOSE YOUR BUSINESS for Withholding purposes please complete and submit the appropriate forms.

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