STATE OF NEW JERSEY
Department of the Treasury
Division of Taxation
PO Box 269
Trenton, NJ 08695-0269
Employee’s Certicate of Nonresidence In New Jersey
Print or Type
First Name MI Last Name Social Security Number
City State ZIP Code
I hereby declare, under penalties of perjury, that I am a resident of the State of Pennsylvania and that, pursuant to a reciprocal
agreement existing between that State and the State of New Jersey, I claim exemption from withholding of New Jersey Gross
Income Tax on compensation paid to me in the State of New Jersey and authorize my employer to withhold Pennsylvania
personal income taxes on my behalf.
Note: If you change your residence from Pennsylvania to any other state, you must notify your employer within 10 days.
Under the Servicemember Civil Relief Act (SCRA), as amended by the Military Spouses Residency Relief Act, you may be
exempt from New Jersey Income Tax on your wages if you reside in New Jersey but have chosen a state other than New Jersey
as your legal residence. If you claim exemption under the SCRA, attach a copy of your spousal military identication card to
I certify that I am not subject to New Jersey withholding. I meet the conditions set forth under the Servicemember Civil Relief Act,
as amended by the Military Spouses Residency Relief Act.
New Jersey Employer
You are required to have a copy of this form on le for each employee receiving compensation paid in New Jersey and who
is a resident of Pennsylvania and claims exemption from withholding of New Jersey Gross Income Tax under the reciprocal
agreement between New Jersey and Pennsylvania or who claims exemption from withholding of New Jersey Gross Income Tax
under the Servicemember Civil Relief Act, as amended by the Military Spouses Residency Relief Act. Do not forward this Form
to the Division of Taxation.
This Form May Be Reproduced
Do Not Forward This Form To The Division of Taxation