Form Dr 1059 - Exemption From Withholding For A Qualifying Spouse Of A U.s. Armed Forces Servicemember

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DR 1059 (07/30/13)
*131059==19999*
COLORADO DEPARTMENT OF REVENUE
Denver, CO 80261-0005
Exemption from Withholding for a Qualifying Spouse
of a U.S. Armed Forces Servicemember
For calendar year 20
Exempt Employee Information: Last Name
First Name
Middle Initial SSN
Address
State of Domicile
Military Spouse Information: Last Name
First Name
Middle Initial SSN
Permanent Duty Station
State of Domicile
To qualify for the exemption from wage withholding and the Colorado income exclusion on Form 104PN, all of the following
statements must be true: (Check the True or False boxes on lines 1 through 6 as they apply to the exempt employee)
True
False
1. I am not a member of the U.S. armed forces.
2. I am married to an active duty member of the U.S. armed forces.
3. My military spouse and I are domiciled in a state other than Colorado and have moved here from
that state.
4. My military spouse’s permanent duty station is in Colorado.
5. I am in Colorado solely to accompany my spouse while he/she is stationed in Colorado .
6. I have the same state of residency as the home of record of my military spouse.
If you answered False to any of these six statements, you do not qualify for the exemption and you should not complete
or file this form.
Attach a copy of your dependent military ID card issued by the U.S. Department of Defense.
Give a copy of this form with attached copy of the military ID card to your employer for their records.
Submit a copy of this form with attached copy of the military ID card with your Colorado income tax return or, if electronically
filing, with form DR 1778, or as an E-Flier Attachment in Revenue Online,
Notify your employer immediately if you become ineligible for this exemption.
You must complete a new form DR 1059 each year to maintain your exemption.
See FYI Income 21 for additional information.
Under penalties of perjury, I declare that the wages I earn for my services performed in Colorado are exempt from
Colorado income tax because I meet the conditions of the Military Spouse Residency Relief Act (P.L. 111-97) and that to
the best of my knowledge and belief, this form is true, correct, and complete.
Employee Signature
Date
(MM/DD/YY)

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