Form Pwh-Ww - Performer Or Performing Entity Request For Waiver Of Withholding Page 2

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Declaration by Nonresident Performer With Annual Income From All Sources of $8,000 or Less

I am not a resident of Massachusetts and reside at the address shown above. I expect during the calendar year to have income from all sources, both inside

and outside Massachusetts, of $8,000 or less. If my total income exceeds $8,000 during the calendar year, I will promptly inform you. I understand that,

even if Massachusetts income tax is not withheld from the payment made to me for my performance in Massachusetts at the above-named venue on the

above-specified date(s) of performance, the payment remains subject to Massachusetts income tax. I declare under penalty of perjury that the information

contained on this form is, to the best of my knowledge and belief, true, complete, and correct. I understand that the penalty for willfully making a false state-

ment to DOR is a fine of not more than $1,000, or imprisonment for not more than two and one-half years, or both.

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