Form Nj 165 – Fill Out and Use This PDF

NJ-165 STATE OFNEWJERSEY

12-09, R-5	Department of theTreasury
	Division ofTaxation
	POBox 269
	Trenton, NJ 08695-0269

EMPLOYEE’S CERTIFICATE OFNONRESIDENCE IN NEWJERSEY

PleasePrintorType

First Name

MI

Last Name

Social Security No.

StreetAddress

City

State

Zip Code

PENNSYLVANIARESIDENTS

I hereby declare, under penalties of perjury, that I am a resident of the State of Pennsylvania and that, pursuant to a reciprocal agreementexistingbetweenthatStateandtheStateofNewJersey,IclaimexemptionfromwithholdingofNewJerseyGrossIncome 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, youmustnotifyyour employer within 10 days.

__________________________	_____________________________________________________________________
(Date)	(Signature)
	MILITARYSPOUSES

Under the Servicemember Civil ReliefAct (SCRA), as amended by the Military Spouses Residency ReliefAct, you may be exempt from New Jersey income tax on your wages if (i) your spouse is a member of the armed forces present in New Jersey in compliance with military orders; (ii) you are present in New Jersey solely to be with your spouse; and (iii) you maintain your domicile in another state. If you claim exemption under the SCRA, attach a copy of your spousal military identification card to Form NJ-165.

I certify that I am not subject to New Jersey withholding. I meet the conditions set forth under the Servicemember Civil ReliefAct, as amended by the Military Spouses Residency ReliefAct.

__________________________	_____________________________________________________________________
(Date)	(Signature)

NEWJERSEYEMPLOYER:

You are required to have a copy of this form on file 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 entered into between New Jersey and Pennsylvania or who claims exemption from withholding of New Jersey Gross Income Tax under the Servicemember Civil ReliefAct, as amended by the Military Spouses Residence ReliefAct. Do not forward this Form

to the Division ofTaxation.

MAYBE REPRODUCED

DO NOT FORWARD THIS FORM TO THE DIVISION OF TAXATION