New York State Department of Taxation and Finance
New York State Certificate of
Exemption from Withholding
First name and middle initial
Social security number
( number and street or rural route )
City, village, or post office
Employee’s certification — This is to certify that I am an enrolled member of the
Indian tribe/nation and that I live on and my income is earned from employment on the
I will notify my employer within 10 days of any change in my status.
To be used only by a Native American who is not subject to New York State income tax ( see instructions on back ).
IT-2104-IND (8/09) (back)
Employee — If you are an enrolled member of a tribe or
nation recognized by the United States or by New York
The Commissioner of Taxation and Finance may collect and maintain personal
State, and you are a Native American who works and
information pursuant to the New York State Tax Law, including but not limited
to, sections 5-a, 171, 171-a, 287, 308, 429, 475, 505, 697, 1096, 1142, and
lives on that tribe’s reservation, you are not subject to
1415 of that Law; and may require disclosure of social security numbers
state tax on income earned on the reservation. If you
pursuant to 42 USC 405(c)(2)(C)(i).
qualify, file this certificate with your employer and your
This information will be used to determine and administer tax liabilities and,
employer will not withhold New York State tax from your
when authorized by law, for certain tax offset and exchange of tax information
programs as well as for any other lawful purpose.
Information concerning quarterly wages paid to employees is provided to
A penalty of $500 may be imposed for providing false
certain state agencies for purposes of fraud prevention, support enforcement,
evaluation of the effectiveness of certain employment and training programs
information that decreases your withholding amount.
and other purposes authorized by law.
Employer — Do not withhold New York State tax
Failure to provide the required information may subject you to civil or criminal
penalties, or both, under the Tax Law.
from the wages of employees who qualify and file this
This information is maintained by the Manager of Document Management,
certificate with you. If the employee’s status changes, you
NYS Tax Department, W A Harriman Campus, Albany NY 12227;
must begin to withhold New York State tax.
telephone (518) 457-5181.
Keep this form with your records; do not send it to the
New York State Tax Department.