Ohio Form It 4nr - Employee'S Statement Of Residency In A Reciprocity State

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Ohio Form IT 4NR

Statement of Residency

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IT 4NR

Employee’s Statement of Residency

Rev. 5/07

in a Reciprocity State

Print full name

Social Security number

Home address and ZIP code

Ohio employers: You are required to have a copy of this form on ﬁ le for each employee who is a resident of Indiana, Kentucky, West Virginia, Michigan

or Pennsylvania receiving compensation paid in Ohio and who claims exemption from withholding of Ohio income tax under the reciprocal agreements

between Ohio and these other states.

Employees residing outside Ohio and in a state with whom Ohio has reciprocity: If you are a resident of a state with whom Ohio has reciprocity, you

may claim exemption from withholding of Ohio income tax by completing this form and ﬁ ling it with your employer under the reciprocal withholding agree-

ments between Ohio and these states.

Note: If you change your residence from the state speciﬁ ed herein to any other state, you must notify your employer within 10 days.

I hereby declare, under penalties of perjury, that I am a resident of the state of

and that, pursuant to an agreement existing

between that state and the state of Ohio, I claim exemption from withholding of Ohio income tax on compensation paid to me in the state of Ohio.

Signature

Date