Form Rev-419-As I - Employe'S Nonwithholding Application - Department Of Revenue
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1REV-419 AS I (2-89)
EMPLOYE'S
NONWITHHOLDING
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
APPLICATION
TAX YEAR 19 _______
BUREAU OF BUSINESS TRUST FUND TAXES
DEPT. 280904
Please Print or Type
HARRISBURG, PA 17128-0904
EMPLOYE INSTRUCTIONS: Who is Eligible For NonWithholding - You may be entitled to nonwithholding of PA State
Income Tax if you incurred no liability for income tax the preceding tax year and you anticipate that you will incur no lia-
bility for income tax the current tax year, according to the Special Tax Provisions of Act 32 of 1974. Act 32 provides low
income individuals a complete or partial tax forgiveness, with specific instructions contained in the current tax year’s
Pennsylvania Individual Income Tax Forms and Instructions Booklet.
When to Claim - File this certificate with your employer as soon as you determine you are entitled to claim nonwith-
holding. You must file a certificate each year to continue to be eligible.
Multiple Employers - If you are employed by more than one employer, you may claim eligibility for nonwithholding with
each employer if your anticipated income total will not cause you to incur any PA State Income Tax liability in the cur-
rent tax year and you had no liability for income tax the preceding tax year.
When You Must Revoke This Certification - You must revoke this certification within 10 days from the day you antic-
ipate you will incur PA State Income Tax liability for the current tax year. To discontinue or revoke this certification of
nonwithholding, submit notification in writing to your employer.
Expiration Date - This certificate expires on December 31.
Exemption - Claimants who qualify for complete tax forgiveness must file a PA-40, Pennsylvania Individual Income Tax
Return, and Schedule SP to claim tax forgiveness.
EMPLOYER INSTRUCTIONS: If the Pennsylvania taxable gross compensation of any employe who has submitted a
nonwithholding application exceeds $1575 for any quarter, the employer promptly must forward a copy of this applica-
tion to the PA Department of Revenue, Bureau of Business Trust Fund Taxes, Dept. 280904, Harrisburg, PA 17128-0904
for approval. If the Department disapproves the application, the employer must immediately commence withholding at
the regular rate.
CUT HERE
SEND TO THE COMMONWEALTH OF PENNSYLVANIA
(EMPLOYE COMPLETES INFORMATION BELOW AND SIGNS)
Employe name: first,
middle initial,
last
Social Security Number
Home Address
Telephone Number
(
)
City
State
Zip Code
Under penalties of perjury, I certify that I did not incur any State Personal Income Tax liability during the preceding
tax year AND, I will not incur any liability this current tax year.
Employe’s Signature
Date
(EMPLOYER COMPLETES INFORMATION BELOW AND SIGNS)
Employer name:
Federal Employer Identification Number
Business Address
Telephone Number
(
)
City
State
Zip Code
Employer’s Signature
Employee’s Quarterly Compensation
$
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