Form Wv/it-104 - West Virginia Employee'S Withholding Exemption Certificate (Page 3 of 20) in pdf

Form Wv/it-104 - West Virginia Employee'S Withholding Exemption Certificate Page 3

WEST VIRGINIA CERTIFICATE OF NONRESIDENCE

WV/IT-104

Rev. 1/07

To be completed by employees who reside in Kentucky, Maryland, Ohio, Pennsylvania or Virginia.

If you are a resident of Kentucky, Maryland, Ohio, Pennsylvania or Virginia and your only source of income from West Virginia is wages or

salaries, you are exempt from West Virginia Personal Income Tax Withholding. Upon receipt of this form, properly completed, your

employer is authorized to discontinue the withholding of West Virginia Income Tax from your wages or salaries earned in West Virginia.

Name_____________________________________________

Social Security Number ______________________________

Address________________________________________________________________________________________________________

City________________________________________

State_____________________

ZipCode______________________

I hereby certify, under penalties provided by law, that I am not a resident of West Virginia, that I reside in the State of ________________

and live at the address shown on this certificate, and request is hereby made to my employer to NOT withhold West Virginia income tax from

wages paid to me. If at any time hereafter I become a resident of West Virginia, or otherwise lose my status of being exempt from West

Virginia withholding taxes, I will properly notify my employer of such fact within ten (10) days from the date of change so that my employer

may then withhold West Virginia income tax from my wages.

I certify that the above statements are true, correct, and complete.

Date__________________________

Signature____________________________________________

Form Wv/it-104 - West Virginia Employee'S Withholding Exemption Certificate Page 3