NATIVE AMERICAN STATE INCOME TAX WITHHOLDING EXEMPTION CERTIFICATE
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 5516, 5517, and EO 9397.
PRINCIPAL PURPOSE(S): To enable a Native American service member to stop State income taxes withholding from
ROUTINE USE(S): The information obtained will become part of the active duty pay system of records of the service
concerned and may be disclosed to routine users of these records (including State tax authorities) as disclosed in its
record system notice.
DISCLOSURE: Disclosure is voluntary. Failure to complete this form will result in withholding of State income taxes from
your pay. Disclosure of SSN is voluntary. However, to avoid erroneous application of your withholding exemption to the
account of another member, this exemption certificate will not be processed without your SSN.
1. NAME (Last, First, Middle Initial)
2. SOCIAL SECURITY NUMBER
3. MILITARY ADDRESS (Unit, Street, City, State, ZIP Code)
4. CURRENT MAILING ADDRESS (Street, City, State, ZIP Code)
5. NAME OF FEDERALLY RECOGNIZED TRIBE THAT YOU ARE A MEMBER OF
6. NAME OF FEDERALLY RECOGNIZED TRIBAL RESERVATION OR INDIAN COUNTRY THAT YOU CLAIM AS YOUR DOMICILE (Include the
name of the State the reservation is located within)
7. I CERTIFY THAT I ANTICIPATE MEETING THE TWO CONDITIONS NECESSARY TO BE EXEMPT FROM WITHHOLDING
FOR THE CALENDAR YEAR
. I ALSO DECLARE THAT I WILL IMMEDIATELY NOTIFY THE FINANCE OFFICER
OF ANY CHANGES THAT AFFECT MY WITHHOLDING STATUS.
8. SIGNATURE OF APPLICANT
9. DATE (YYYYMMDD)
Completing this certificate allows you to claim exemption from State income tax withholding on your military
compensation if you satisfy the following tests:
1. You claim as your State of legal residency/domicile a federally recognized tribal reservation or Indian Country.
2. You are an enrolled member of that federally recognized Native American tribe.
If you satisfy these conditions, the Soldiers' and Sailors' Civil Relief Act provides that your tax home remains on the
reservation/in Indian country. Consequently, you may stop State income tax withholding on your military compensation.
If you have any doubt with regard to your State of legal residence/domicile, you are advised to see your Legal
Assistance Officer (JAG representative) for advice prior to completing this form.
Effective date of exemption election. Withholding of State income tax will stop the month after the month in which you
file this certificate. DFAS cannot make retroactive adjustments.
DD FORM 2058-2, JUL 2002