Form Il-W-5-Nr - Employee'S Statement Of Nonresidence In Illinois
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Illinois Department of Revenue
IL-W-5-NR
Employee’s Statement of Nonresidence in Illinois
Must I complete this form?
To employers:
You must complete Part 1 of this form if
You are required to have a copy of this form on file for each employee who
• you are a resident of Iowa, Kentucky, Michigan, or Wisconsin, or
• is a resident of Iowa, Kentucky, Michigan, or Wisconsin; receives com-
• your spouse is in the military, you and your spouse are both residents of
pensation paid in Illinois; and elects to claim exemption from withhold-
the same state (other than Illinois) and you are in Illinois only because
ing of Illinois Income Tax under the reciprocal withholding agreements
your spouse is stationed here by the military,
between Illinois and these states, OR
and your wages are exempt from withholding of Illinois Income Tax under the
• is exempt from Illinois Income Tax on compensation under the Military
reciprocal withholding agreements between Illinois and these states or under
Spouses Residency Relief Act.
the Military Spouses Residency Relief Act. You must file your completed Form
IL-W-5-NR with your Illinois employer. If you change your state of residence,
you must notify your employer within ten days.
Part 1: Employee information
Part 2: Employer information
_____ ______ _____ - _____ _____ - _____ _____ _____ _____
_____ _____ - _____ _____ _____ _____ _____ _____ _____
Social Security number
Federal employer identification number
______________________________________________________________________
______________________________________________________________________
Name
Name
______________________________________________________________________
______________________________________________________________________
Mailing address
Mailing address
______________________________________________________________________
______________________________________________________________________
City
State
ZIP
City
State
ZIP
I declare under penalties of perjury that
I am a resident of the state of:
Iowa
Kentucky
Michigan
Wisconsin, OR
My spouse and I are residents of (write the 2-letter abbreviation for your
state of residency) ____ and I am in Illinois only because my spouse is a mem-
ber of the US military who is stationed in Illinois.
______________________________________________________________________
Employee’s signature
Date
This form is authorized under the Illinois Income Tax Act. Disclosure of this information is required.
Failure to provide information may result in this form not being processed and may result in a penalty.
IL-W-5-NR (R-12/10)
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