Fillable Printable Leave Letter Format For tax forms
Fillable Printable Leave Letter Format For tax forms
Leave Letter Format For tax forms
PURDUE UNIVERSITY
PAYROLL DEPARTMENT
401 S. Grant Street
WEST LAFAYETTE, IN 47907-1064
CERTIFICATE OF RESIDENCE
For the reciprocal States of Kentucky, Michigan, Ohio, Pennsylvania, and Wisconsin
(To Be Used For Claiming Exemption from Indiana Adjusted Gross Income Withholding)
1) My Name is:
2) My Home State Resident Address is:
3) I am employed by Purdue University.
4) I am a resident of the state of effective (date), and as such
am covered by the Reciprocal Agreement between my home state and the State of Indiana with respect to
the payment of state income tax.
5) I do not own personal property in Indiana, and income from salaries, wages, and commissions received from
Indiana sources are taxable in the above state of residence and not subject to the Indiana Income Tax
as a result of the reciprocal tax agreement.
6)
On the basis of the facts presented above, I have good reason to believe that I am exempt from the payment
Indiana Adjusted Gross Income Tax, and hereby request Purdue University to discontinue the withholding
of said tax.
7) I understand that the exemption is for Indiana State Income Tax ONLY and does not affect the withholding
requirements of the Indiana County Adjusted Income Tax (CAGIT), County Economic Development Tax (CEDIT),
or County Option Income Tax (COIT). I further understand that I will be required to file an Indiana Income Tax
Form IT-40RNR to report the county tax withheld.
8) I understand that any exemption from withholding of tax permitted by reason of the filing of this statement is not
a determination by the Commissioner of Indiana Department of Revenue that any remuneration paid to me for
any services performed during the taxable year is excludable from gross income.
9) The exemption from withholding Indiana Income Tax will remain in effect until I advise Purdue
University via memo or letter that I no longer qualify for the exemption.
10) I declare under the penalties of perjury that this statement has been examined by me and to the best of my
knowledge and belief is true and correct.
Date Signature
Social Security Number Department Name & Number
Purdue University
Payroll Form 52
