1. Declaration Control Number (DCN)
5
00
EPV
ARIZONA FORM
Arizona Individual Income Tax
AZ-140V 1000 SYS
0184
2004
Payment Voucher for Electronic Filing 218 40
1 Your social security number 2 Spouse’s social security number 3 Amount of payment
$
4 Your first name Spouse’s first name Last name POSTMARK
Please Print or Type
Present home address - number and street, rural route
City, town or post office State Zip code
Do not send cash. Check or money order is to be made payable to the
NOTE: To avoid interest and penalties you must pay the full amount of your
Arizona Department of Revenue. Include your social security number
tax by April 15, 2005. You will not receive an additional notice from the
and “2004 Tax” on the check or money order. Attach your payment
Arizona Department of Revenue unless an error exists with your return.
to this form and mail both to: Arizona Department of Revenue,
PO Box 29237, Phoenix AZ 85038-9237
ADOR 91-0016 (04)