REVENUE DIVISION
                                                                                                                             Individual Income Tax
                                                      STATE OF ARKANSAS                                                      1816 W 7th St., Room 2300
                                                                                                                                  Post Office Box 3628
                                            Individual Income Tax                                  Little Rock, Arkansas 72203-3628
                                                                                                                                  Phone:  (501) 682-1100
                                                    Penalty and Interest                                                          Fax:  (501) 682-7692
                                                      Waiver Request                                                              www.dfa.arkansas.gov

                                            Please type or print when filling out this form

SECTION I - TAXPAYER INFORMATION

  Individual                Composite       Fiduciary 

Please use one form per account. 
1 Primary Legal Name (First Name, MI, and Last Name)/Entity Name                            2 Primary Social Security Number/FEIN 

3 Spouse’s Legal Name (First Name, MI, and Last Name)                                       4 Spouse’s Social Security Number

5 Mailing Address, City, State, and Zip Code

6 Daytime Phone Number

7 E-mail Address

SECTION II - PENALTY WAIVER REQUEST

Check all that apply:       Failure to File Penalty   Failure to Pay Penalty                  UEP (Under Estimate Penalty)        Interest

For Tax Year(s):

Reason for Request (check all that apply):          Illness                Natural Disaster   Other
Please explain in detail why your penalty and/or interest should be waived:

SECTION III - SIGNATURE

  Primary Signature/Authorized Party                                       Date                    Daytime Phone Number

  If Joint Return, Spouse’s Signature                                      Date                    Daytime Phone Number
Penalty Waiver (R 12/8/2022)
                                      Mail, Fax, or Email COMPLETED Form To:

                MAIL:                                                      FAX:                    EMAIL: 
ARKANSAS STATE INCOME TAX
   PO BOX 3628                                        501-682-7692                            individual.income@dfa.arkansas.gov
   LITTLE ROCK, AR 72203