Form Wh-4mil - Earned Income Withholding Tax Exemption Form
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1WH-4MIL
ANNUAL NONRESIDENT MILITARY SPOUSE
State Form
(1-10)
Earned Income Withholding Tax Exemption Form
This form is for the employer’s records. Do not send this form to the Department of Revenue.
Employee Name
Employee Social Security Number
Military Servicemember Spouse’s Name
Military Servicemember Spouse’s Social Security Number
Address where you both currently reside
Street
City
State
Zip Code
Form WH-4MIL is to be used only for employees claiming exemption from Indiana’s income tax withholding
requirements because they meet the conditions set forth under the Servicemembers Civil Relief Act, as amend-
ed by the Military Spouses Residency Relief Act (P.L. 111-97).
In order to qualify you must meet the conditions below, complete this form in full, and certify that you are not
subject to Indiana withholding tax because you meet the conditions set forth below.
1. My spouse is a military servicemember ....................................................................(check one)
Yes
No
2. I am NOT a military servicemember ..........................................................................(check one)
Yes
No
3. My military servicemember spouse has current military orders assigning him or
her to a military location in Indiana .............................................................................(check one)
Yes
No
4. I and my military servicemember spouse live at the same address ...........................(check one)
Yes
No
Yes
No
5. My domicile is a state other than Indiana ..................................................................(check one)
If yes, enter 2-letter state code for your state
6. My military servicemember spouse’s domicile is the same as mine ..........................(check one)
Yes
No
If you checked yes to all six statements above, your earned income is exempt from Indiana withholding tax.
Start Military Spouse Exemption. If you answered “YES” to ALL of the above statements, check the box and
note the start date here
Terminate Military Spouse Exemption. If the answer to any of the six statements above changes to “NO”,
Indiana tax must be withheld. Check the box and enter the termination date here
Under penalties of perjury, I certify that I am not subject to Indiana withholding tax because l meet the conditions
set forth under the Servicemembers Civil Relief Act, as amended by the Military Spouses Residency Relief Act
(P.L. 111-97).
Employee’s Signature
Date
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