Ohio Form IT 4NR
                                                                                                         Statement of Residency

                                    ✁ please detach here

                                                                                                                                    IT 4NR
                                    Employee’s Statement of Residency                                                               Rev. 5/07
                                    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 fi le 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 fi ling it with your employer under the reciprocal withholding agree-
ments between Ohio and these states.
Note: If you change your residence from the state specifi ed 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