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Form 10834 Fillable Statement of Exemption & 2013 IRS Levy Exemption Chart
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)(2013) (Click to print form and IRS publication) Print (Click to select) Unchecked (Click to select) Unchecked (Press Enter to begin a new line of text) (text) (text) (text) (text) (text) (text) (text) (Type digits only without dashes) * ADDITIONAL STANDARD 1 2 3 4 100 00 150 00 200 00 50 00 100 00 200 00 300 00 400 00 1016 67 plus 325 for each exemption 1022 92 106 92 1066 67 1066 671229 17 1069 231219 23 109 42 1094 23 11 54 5 77 113 46 1134 62 115 38 57 69 1158 33 1158 33 117 31 plus 75 for each exemption 1185 42 121 92 1229 17 124 42 1244 23 125 00 250 00 125 00 62 50 1320 83 1347 92 136 92 1369 23 1395 83 1483 33 1483 33 1666 67 172 12 plus 75 for each exemption 1720 83 18 46 9 23 4 62 13 85 1808 33 192 31 1991 67 2045 83 2133 33 23 46 plus 15 for each exemption 2316 67 234 62 plus 150 for each examption 234 62 plus 150 for each exemption 234 62 plus 75 for each exemption 2370 83 2458 33 247 12 254 17 plus 162 50 for each exemption 2641 67 267 31 2695 83 2966 67 322 12 34 42 plus 15 for each exemption 342 31 344 23 plus 150 for each exemption 372 92 plus 162 50 for each exemption 38 46 384 62 384 62534 62 397 12 416 67 417 31 459 62 46 92 plus 15 for each exemption 469 23 plus 150 for each exemption 472 12 49 42 492 31 492 31567 31 494 23 508 33 plus 162 50 for each exemption 508 33 plus 325 for each exemption 53 46 534 62 535 42 547 12 567 31 57 69 28 85 579 17 609 62 622 12 64 42 644 23 68 46 684 62 684 62 697 92 741 67 745 83 plus 325 for each exemption 76 92 769 23 79 42 794 23 83 46 833 33 834 62 860 42 904 17 91 92 919 23 92 31 184 62 46 15 138 46 92 31 46 15 23 08 69 23 94 42 944 23 98 46 984 62 995 83 A Notice of Levy on Wages Salary and other Income was served on my income To assist in figuring the amount of my income that is exempt A single taxpayer who is paid weekly and claims three Examples A taxpayer who is married files jointly These tables show the amount exempt each pay period 1 AATEMENT OF EXEMPTIONS Additional Exempt Amount ADOR 10834 (12/12) Any Other Filing Status Arizona Department of Revenue Arizona Department of RevenueArizona Department of Revenue at Least 65 Years Old and/or Blind 2 below and on reverse Biweekly Biweekly Biweekly384 62 Biweekly619 23 Catalog Number 11439T Check if blind Check if over 65 years old contact number on the face of the levy form Daily Daily Daily38 46 Daily61 92 Deductions Department of Treasury Internal Revenue Dependent s Name (last first initial) Relationship EMPLOYEE: EMPLOYER: exemption See reverse for examples Note: The amount exempt from levy may change annually If it does and this levy remains in force next exemption status will default to single one exemption Filing Status Filing Status: Filing Status: for the taxpayer) has $769 23 4 frequency of your paydays and use that amount as your exemption unless you and / or your spouse are over age 65 and / or blind If so you from the levy I certify that I am entitled to the exemptions below Head of Household I certify that I can claim the people named below as personal exemptions on my income tax return No one listed is my minor child to whom (as If the taxpayer in number 1 is over 65 and writes space on Parts 3 4 & 5 of the levy $3 if the taxpayer in number 3 is over 2 in the ADDITIONAL $861 54 is exempt has $342 31 exempt from levy 2 INSTRUCTIONS TO COMPUTE AMOUNT EXEMPT FROM LEVY Married Filing Joint Return (and Qualifying Widow(er)s) Married Filing Separate Return may claim an additional exemption To compute that additional exemption Use Table B on the reverse and match your filing status your number Monthly Monthly1070 83 Monthly1341 67 Monthly833 33 More Than 6 More Than 6 Number of Exemptions Claimed on Statement Number of Exemptions Claimed on StatementPay Period of additional deductions checked above and the frequency of your payday Add that amount to the amount computed in Table A to get your total Pay Period PO BOX 29070 PHOENIX AZ 85037 9070 provided may be verified Under penalties of law I declare that this statement of exemptions and filing status is true Publication required by court or administrative order) I make support payments that are already exempt from levy I understand that the information I have Semi monthly Semimonthly Semimonthly Semimonthly670 83833 33 Signature Date Single Single or Head of Household STSTA Table for Figuring Additional Exempt Amount for Taxpayers Tables for Figuring Amount Exempt from Levy on Wages Salary and Other Income (Forms 668 W(ACS) 668 W(c)(DO) and 668 W(ICS)) Taxpayer s Spouse: Additional Taxpayer: Additional TEMENT OF EXEMPTIONSTEMENT OF EXEMPTIONS the exemption status will default to single one exemption Please return the executed original using the enclosed envelope See instructions the following statement must be completed and signed by the person claiming the exemption If the statement is not completed by the employee The following statement must be completed and signed in order to claim an exemption from levy If the statement is not completed by you your the reverse find the filing status which matches your current income tax filing status Using that table find the number of exemptions and the The tables below show the amount of an individual's income that is exempt from a notice of levy To compute the amount exempt from levy add the total of names entered above including yours and your spouse s and then in Table A on To: Employee To: Employer Under the provisions of ARS 42 1204 the department allows a certain amount to be exempted from levy Before such an exemption is granted used to collect delinquent tax in 2013 Weekly Weekly Weekly309 62 www irs gov year filing a new Statement of Exemptions will allow your employer to use the new year s exemption table To obtain a new form phone the