Form It 4nr - Employee'S Statement Of Residency In A Reciprocity State printable pdf download

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

IT 4 NR

Rev. 5/07

✁ ✁ ✁ ✁ ✁

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Employee’s Statement of Residency

IT 4NR

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 file 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 filing it with your employer under the reciprocal

withholding agreements between Ohio and these states.

Note: If you change your residence from the state specified 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