Form D-4a, Certificate Of Nonresidence In The District Of Columbia
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1
2Government of the
District of Columbia
Enter Year
First name
M.I. Last name
Temporary DC address (number and street)
Social security number
Permanent address (number and street)
Apartment number
City
State
Zip code + 4
Country or U.S. commonwealth
Signature
Under penalties of law, I certify that my permanent residence is not in DC and that I will not be residing in DC for 183 days or more in the tax year.
Signature
Date
Revised 08/2011
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