Form Hw-6 - Employee'S Statement To Employer Concerning Nonresidence In The State Of Hawaii - 2013 Page 2

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FORM HW-6

(REV. 2012)

PAGE 2

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17. Do you file Hawaii resident income tax returns? ........................................................................................................Yes

18. With which Internal Revenue Service Center do you file your federal income tax returns?

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19. Are you a U.S. citizen? ...............................................................................................................................................Yes

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If you checked “No,” are you a permanent resident alien of the U.S.? ........................................................................Yes

If you are not a permanent resident alien of the U.S., state the type of visa you have.

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20. Are you in Hawaii in compliance with military or naval orders of the United States? .................................................Yes

If you checked “Yes,” enclose a true copy of your military or naval orders.

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21. Are you in Hawaii while engaged in aviation or navigation? .......................................................................................Yes

If you checked “Yes,” enclose a true copy of a letter from your employer describing your services

performed in aviation or navigation.

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22. Are you in Hawaii while a student at any institution of learning? ................................................................................Yes

If you checked “Yes,” enclose a true copy of an appropriate document certified by the officials of the

school, college, or university, evidencing your enrollment in their class or course.

23. Are you the spouse of a nonresident service member, crew member, or student who came to Hawaii;

your principal reason for moving to Hawaii is to accompany your spouse; and it is your intention to

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leave Hawaii when your spouse is transferred, discharged, or graduates? ................................................................Yes

If you checked “Yes,” enclose true copies of your spouse’s military or naval orders and Leave and Earning

Statement, and your unexpired military spouse identification card; a letter from your spouse’s employer

describing your spouse’s services performed in aviation or navigation; or appropriate document certified by

the officials of the school, college, or university evidencing your spouse’s enrollment in their class or course.

Note:

If you checked “No” to question 2, stop here. If you checked “Yes” to question 2, answer questions 24 through 34.

24. List the years you were a resident of Hawaii.

25. Explain why you gave up your Hawaii residency.

26. If you were domiciled in Hawaii, on what date did you terminate your Hawaii domicile?

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27. Did you move out of Hawaii to your new domicile? ....................................................................................................Yes

If you checked “Yes,” on what date? (Note: This date may be different than the date in number 26.)

28. What specific steps did you take to terminate your Hawaii domicile and on what date did you take such steps?

29. In what state or country did you establish your new domicile?

30. When did you begin working in that state or country?

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31. Did your family move out of Hawaii to your new domicile? .........................................................................................Yes

If you checked “Yes,” on what date?

32. In the state or country you are now claiming as your new domicile, have you:

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Purchased a home? ............................................................................................................................................Yes

If you checked “Yes,” on what date was it purchased?

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Sent your children to schools in that state or country? .......................................................................................Yes

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Joined any social, business, or church groups in that state or country? .............................................................Yes

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Registered to vote in that state or country? ........................................................................................................Yes

33. What other specific steps did you take to establish your new domicile?

34. Please enter any other facts or circumstances relating to your change of domicile that you feel should be

considered.

I declare under the penalties of section 231-36 of the Hawaii Revised Statutes, that I have answered all the above questions which I

am required to answer, and that my answers are true and correct.

Employee’s Signature:

Date: