please detach here
Employee’s Statement of Residency
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 within10 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.
______________________________________________________________________________________________________ _____________________________
Rev. 12/00
Signature Date