Illinois Department of Revenue
IL-W-5-NR Employee’s Statement of Nonresidence in Illinois
To employers:
You are required to have a copy of this form on file for each employee who
• is a resident of Iowa, Kentucky, Michigan, or Wisconsin; receives com-
pensation paid in Illinois; and elects to claim exemption from withhold-
ing of Illinois Income Tax under the reciprocal withholding agreements
between Illinois and these states, OR
• is exempt from Illinois Income Tax on compensation under the Military
Spouses Residency Relief Act.
Part 2: Employer information
_____ _____ - _____ _____ _____ _____ _____ _____ _____
Federal employer identification number
______________________________________________________________________
Name
______________________________________________________________________
Mailing address
______________________________________________________________________
City State ZIP
Must I complete this form?
You must complete Part 1 of this form if
• you are a resident of Iowa, Kentucky, Michigan, or Wisconsin, or
• your spouse is in the military, you and your spouse are both residents of
the same state (other than Illinois) and you are in Illinois only because
your spouse is stationed here by the military,
and your wages are exempt from withholding of Illinois Income Tax under the
reciprocal withholding agreements between Illinois and these states or under
the Military Spouses Residency Relief Act. You must file your completed Form
IL-W-5-NR with your Illinois employer. If you change your state of residence,
you must notify your employer within ten days.
Part 1: Employee information
_____ ______ _____ - _____ _____ - _____ _____ _____ _____
Social Security number
______________________________________________________________________
Name
______________________________________________________________________
Mailing address
______________________________________________________________________
City State ZIP
I declare under penalties of perjury that
I am a resident of the state of:
Iowa Kentucky Michigan Wisconsin, OR
My spouse and I are residents of (write the 2-letter abbreviation for your
state of residency) ____ and I am in Illinois only because my spouse is a mem-
ber of the US military who is stationed in Illinois.
______________________________________________________________________
Employee’s signature Date
IL-W-5-NR (R-12/10)
This form is authorized under the Illinois Income Tax Act. Disclosure of this information is required.
Failure to provide information may result in this form not being processed and may result in a penalty.
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