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CLEAR FORM
Form NRW-Exemption (REV 7/12)
AFFIDAVIT BY NONRESIDENT OF EXEMPTION
This form is to be completed by a nonresident member to certify certain exemptions from
the O.C.G.A. § 48-7-129 nonresident withholding requirements.
This form is to be completed by the nonresident member and returned to the entity.
A copy of the completed form should be attached to the income tax return filed by the
entity each year.
Name of Nonresident Member
Nonresident Member’s Federal Identification
Number (SSN or FEIN)
Street Address
Tax Year Ending
City
State
ZIP Code
Telephone Number
Entity’s Name
Entity’s Federal Identification Number
Please check the box that applies and sign on page 2.
1. C-Corporation, individual or fiduciary member exemption pursuant to Regulation 560-7-
8-.34(2) (note only needs to be made one time):
The above named member hereby certifies that it:
a. Agrees to be subject to personal jurisdiction in this State for all income tax purposes, files
returns, and pays all Georgia tax liabilities due, for the current year and future years in which
it is a member and the entity owns property in Georgia, does business in Georgia, or
otherwise derives income from Georgia sources;
b. Has provided this form to the Entity in which it is a member on or before the due date
(without extension) for filing the Entity’s income tax return for the taxable year for which the
withholding is required; and
c. Will make estimated income tax payments if required.
2. Exempt organization member exemption pursuant to Regulation 560-7-8-.34(2) (note
must be made annually):
The above named member hereby certifies that its share of the taxable income sourced to
this state (for which this exemption is claimed) does not result in unrelated business taxable
income.
3. Insurance company member exemption pursuant to Regulation 560-7-8-.34(2) (note
must be made annually):
The above named member hereby certifies that it actually pays a tax to Georgia on its
premium income and is not subject to Georgia income tax.
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