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IT 4NR
Rev. 5/07
Ohio IT 4NR
Statement of Residency
hio
Department of
Taxation
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 within 10 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.
Signature Date
