Form Nrw-Exemption - Affidavit By Nonresident Of Exemption Page 2
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Form NRW-Exemption (REV 7/12)
4. Tiered Situation Exemption pursuant to Regulation 560-7-8-.34(5) (note must be made
annually):
The above named nonresident entity member:
a. Elects to withhold at the rate of 4 percent with respect to its nonresident members’ shares
of the taxable income sourced to this state in the same manner and subject to the same
requirements, exceptions (including this exception but excluding the exception provided in
subparagraph (2)(c) of Regulation 560-7-8-.34), etc. as if such Entity itself was subject to
O.C.G.A. § 48-7-129 and this regulation;
b. Agrees to be subject to personal jurisdiction in this State for all income tax purposes
including the withholding required by O.C.G.A. § 48-7-129, together with related interest and
penalties; and
c. 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.
5. Certain Retirement Accounts Exemption pursuant to Regulation 560-7-8-.34(2) (note
only needs to be made one time):
The above named nonresident entity member is an individual retirement account as defined
by Internal Revenue Code §§ 408(a) and 408(b), a Roth IRA as defined by Internal Revenue
Code §408A, or a qualified employer plan as defined by Internal Revenue Code §409A(d)(2).
The Entity must attach a copy of this to their income tax return each year.
Under penalty of perjury, I swear that the above information is to the best of my knowledge and
belief, true, correct and complete.
__________________________________
___________________________
Signature of Individual, Fiduciary or Authorized
Date
Officer or Tax Matters Person
__________________________________
Print Name of Individual, Fiduciary or Authorized
Officer or Tax Matters Person
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