Revenue Form K-4m - Nonresident Military Spouse Withholding Tax Exemption Certificate
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2Revenue Form K–4M
NONRESIDENT MILITARY SPOUSE
42A804–M (11–10)
Withholding Tax Exemption Certifi cate
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
Part I—To be completed by the employee
____________________________________________________
____________________________________________________
Employee Name
Employee Social Security Number
____________________________________________________
____________________________________________________
Military Servicemember’s Name
Military Servicemember’s Social Security Number
Address where both currently reside
Street __________________________________________________________________________________________________________
City ______________________________________________
State ______________
Zip Code ____________________________
Form K – 4M is to be used only for employees claiming exemption from Kentucky’s income tax withholding requirements
because they meet the conditions set forth under the Servicemembers Civil Relief Act, as amended by the Military
Spouses Residency Relief Act (P. L. 111–97).
In order to qualify the employee must complete this form in full, certify that the employee is not subject to Kentucky
withholding tax because the employee meets the conditions set forth below, and provide a copy of the employee’s
military spouse picture ID issued to the employee by the Department of Defense.
1. My spouse is a military servicemember .......................................................................................... (check one)
YES
NO
2. I am NOT a military servicemember ................................................................................................ (check one)
YES
NO
3. My military servicemember spouse has a current military order assigning him or her
to a military location in Kentucky ..................................................................................................... (check one)
YES
NO
4. I and my military servicemember spouse live at the same address ............................................. (check one)
YES
NO
5. My domicile is a state other than Kentucky .................................................................................... (check one)
YES
NO
If yes, enter the 2-letter state code of your state ________
6. My military servicemember spouse’s domicile is the same as mine ............................................ (check one)
YES
NO
7. I am present in Kentucky solely to be with my military servicemember spouse ......................... (check one)
YES
NO
If you checked “YES” to all the statements above, your earned income is exempt from Kentucky withholding tax.
Start Military Spouse Exemption. If you answered “YES” to ALL of the above statements, check the box and note the start date
here _________________________________
Terminate Military Spouse Exemption. If the answer to any of the statements above changes to “NO” Kentucky tax must be
withheld. Check the box and enter the termination date here _________________________________
Under penalties of perjury, I certify that I am not subject to Kentucky withholding tax because I meet the conditions set
forth under the Servicemembers Civil Relief Act, as amended by the Military Spouses Residency Relief Act (P.L. 111–97).
I understand that my state of residency may tax the income I earn in Kentucky.
Employee’s Signature ___________________________________________________________
Date ____________________________________
Part II—To be completed by the employer
Note: An employer shall be held harmless from liability for withholding based on the employee’s representations on this form.
Employer Name
Employer identifi cation number (EIN)
Address
City
State
Zip Code
See “Employer Requirements” for the proper handling of this form.
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