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                                                    http://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 Name (First Name, MI, and Last Name)/Entity Name                                  2 Primary Social Security Number/FEIN 

3 Spouse’s 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 06/16/2020)
  MAIL COMPLETED FORM TO:                                                                     FAX COMPLETED FORM TO:
  ARKANSAS STATE INCOME TAX                                                                        501-682-7692
                PO BOX 3628                                                OR
  LITTLE ROCK, AR 72203