Form K-4fc - Fort Campbell Exemption Certificate (Page 3 of 3) in pdf

Form K-4fc - Fort Campbell Exemption Certificate Page 3

INSTRUCTIONS

Under the provisions of Public Law 105–261, pay and compensation earned at Fort Campbell, Kentucky, military

base is exempt from Kentucky income tax if you are not a resident of Kentucky. KRS 141.010(17) defines “resident”

as an individual domiciled within this state or an individual who is not domiciled in this state, but maintains a

place of abode in this state and spends in the aggregate more than one hundred eighty-three (183) days of the

taxable year in this state.

Employees—If you are not a “resident” of Kentucky, complete Form 42A807 and file with your employer.

Otherwise Kentucky income tax must be withheld from your wages. The address portion of the form must

contain the physical location where you live. A post office box number is unacceptable and will invalidate this

certificate.

It is your responsibility to notify your employer to revoke this certificate 10 days after a move or change of

address to Kentucky.

Penalties—Criminal and civil penalties may be imposed for intentionally supplying false information or

intentional failure to supply information which causes your employer to under-withhold.

Employers—Keep Copy A for your files. Mail Copy B with your name and federal or Kentucky identification

number to the Kentucky Department of Revenue, P .O. Box 181, Station 57, Frankfort, Kentucky 40602-0181,

within 30 days of receipt. After the employee files a complete Form 42A807, you are authorized to discontinue

withholding Kentucky income tax from wages earned at Fort Campbell, Kentucky. If the employee moves or

otherwise changes his/her address to Kentucky, begin withholding Kentucky income tax as required by KRS

141.310 with the first payroll period ending after you receive notice of the change. Check the box in the upper

right corner to indicate this certficate is revoked and enter date. Retain in your files for four years.

Form K-4fc - Fort Campbell Exemption Certificate Page 3