Form 44-016 - Employee'S Statement Of Nonresidence In Iowa
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1Iowa Department of Revenue
Employee’s Statement of Nonresidence in Iowa
Employee’s Full Name
Social Security Number
I hereby declare, under penalty of
perjury, that I am a resident of the
Home Address and Zip Code
state of Illinois and that, pursuant
to an agreement existing between
Employer’s Name
Employer’s Address
that state and the state of Iowa, I
claim exemption from withholding
Iowa Employers:
of Iowa income tax on
You are required to have a copy of this form on file for each employee who is a resident of
compensation paid to me in the
Illinois receiving compensation paid in Iowa and who claims exemption from withholding of
state of Iowa.
Iowa income tax under the reciprocal agreement between Iowa and Illinois.
Signed: _____________________
Employee Resident of Illinois:
If you are a resident of Illinois, you may claim exemption from withholding of Iowa income
Date: _____________ 20 ____
tax by completing this form and filing it with your employer, under the reciprocal agreement
between Iowa and Illinois.
44-016
(08/04/09)
Note: If you change your residence from the state specified to any other state, you must notify your employer within 10 days.
Iowa Department of Revenue
Employee’s Statement of Nonresidence in Iowa
Employee’s Full Name
Social Security Number
I hereby declare, under penalty of
perjury, that I am a resident of the
Home Address and Zip Code
state of Illinois and that, pursuant
to an agreement existing between
Employer’s Name
Employer’s Address
that state and the state of Iowa, I
claim exemption from withholding
Iowa Employers:
of Iowa income tax on
You are required to have a copy of this form on file for each employee who is a resident of
compensation paid to me in the
Illinois receiving compensation paid in Iowa and who claims exemption from withholding of
state of Iowa.
Iowa income tax under the reciprocal agreement between Iowa and Illinois.
Signed: _____________________
Employee Resident of Illinois:
If you are a resident of Illinois, you may claim exemption from withholding of Iowa income
Date: _____________ 20 ____
tax by completing this form and filing it with your employer, under the reciprocal agreement
between Iowa and Illinois.
44-016
(08/04/09)
Note: If you change your residence from the state specified to any other state, you must notify your employer within 10 days.
Iowa Department of Revenue
Employee’s Statement of Nonresidence in Iowa
Employee’s Full Name
Social Security Number
I hereby declare, under penalty of
perjury, that I am a resident of the
Home Address and Zip Code
state of Illinois and that, pursuant
to an agreement existing between
Employer’s Name
Employer’s Address
that state and the state of Iowa, I
claim exemption from withholding
of Iowa income tax on
Iowa Employers:
You are required to have a copy of this form on file for each employee who is a resident of
compensation paid to me in the
Illinois receiving compensation paid in Iowa and who claims exemption from withholding of
state of Iowa.
Iowa income tax under the reciprocal agreement between Iowa and Illinois.
Signed: _____________________
Employee Resident of Illinois:
If you are a resident of Illinois, you may claim exemption from withholding of Iowa income
tax by completing this form and filing it with your employer, under the reciprocal agreement
Date: _____________ 20 ____
between Iowa and Illinois.
44-016
(08/04/09)
Note: If you change your residence from the state specified to any other state, you must notify your employer within 10 days.
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