Elected to Serve
Ann T. Burkholder, Commissioner of the Revenue Telephone: (540) 667-1815
Creamery Building, 21 S Kent Street, Suite 100 FAX: (540) 667-8937
Winchester, VA 22601 TDD: (540) 722-0782
Email: commrevenue@winchesterva.gov Website: www.winchesterva.gov
Certificate of Legal Residence for Service Member
This certificate must be filed by all persons claiming exemption from taxation in the State of
Virginia under the federal Service Member Civil Relief Act.
Service Member Name: ________________________________________________________
Rank: ______________________________ Serial Number: ______________________
Legal Residence Street Address: _________________________________________________
Legal Residence City/County, State: ______________________________________________
State to which State Income Tax is paid: ___________________________________________
Temporary Virginia Residence: ___________________________________________________
____________________________________________________________________________
Vehicle 1 Year, Make, Model: ____________________________________________________
Vehicle 2 Year, Make, Model: ____________________________________________________
Vehicle 3 Year, Make, Model: ____________________________________________________
Vehicle 4 Year, Make, Model: ____________________________________________________
I certify that the above information is all correct and that my legal residence is the street address
and state listed. It is my present intention to return to said place of legal residence at the
termination of my military service. I am not a registered voter in Virginia nor do I file Virginia
income tax. I am temporarily in the State of Virginia in compliance with military orders, and
request that my tangible personal property be assessed in the state and city/county of my legal
residence, as provided for in accordance with the Service Member Civil Relief Act, 50 U.S.C.
App. 571 Sec. 511. None of this personal property is used for a trade or business. I have
enclosed documentation showing my home of record.
____________________________________________________________________________
Signature of Service Member
____________________________________________________________________________
Signature and Printed Name of Commanding Officer, Administering Oath
On this date: _________________________________________________________________
Commissioner of the Revenue, Page 2 of 2
Jointly Owned Property: Personal property jointly owned with a spouse may also qualify for
exemption under the Military Spouses Residency Relief Act. The Act is effective for taxable year
2009 and thereafter. In order to qualify, please complete the following, if applicable
Service Member Spouse Name: __________________________________________________
Legal Residence Street Address: _________________________________________________
Legal Residence City/County, State: ______________________________________________
State to which State Income Tax is paid: ___________________________________________
Temporary Virginia Residence: ___________________________________________________
____________________________________________________________________________
List any jointly owned vehicles not included above:
Vehicle 1 Year, Make, Model: ____________________________________________________
Vehicle 2 Year, Make, Model: ____________________________________________________
Vehicle 3 Year, Make, Model: ____________________________________________________
Vehicle 4 Year, Make, Model: ____________________________________________________
I certify that the above information is all correct and that my legal residence is the street address
and state listed. It is my present intention to return to said place of legal residence at the
termination of my spouse’s military service. I am not a registered voter in Virginia nor do I file
Virginia income tax. I am temporarily in the State of Virginia solely to be with my spouse, who is
here in compliance with military orders, and request that my tangible personal property be
assessed in the state and city/county of my legal residence, as provided for in accordance with
the Service Member Civil Relief Act, 50 U.S.C. App. 571 Sec. 511. None of this personal
property is used for a trade or business. I have enclosed documentation showing my home of
record.
____________________________________________________________________________
Signature of Service Member Spouse
____________________________________________________________________________
Signature of Service Member
Commissioner of the Revenue Office Use Only; Date Received: _________________________