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.

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