IT DA
                                                                                                                                               Rev. 9/15

               Affi davit of Non-Ohio Residency/Domicile for Taxable Year 2015
                              This form is for use only by individuals who are claiming 
                              to be full-year nonresidents for Ohio income tax purposes.

Due date: May 31, 2016. See Ohio Revised Code section 5747.24.
Who must fi le: Please see instructions.
Filing this affi davit does not exempt you from timely fi ling your Ohio income tax return for 2015 and paying any tax due.

 First name                                    M.I.      Last name                             Social Security no.

 Spouse’s fi rst name (only if joint affi davit) M.I.      Last name                             Spouse’s Social Security no. (only if joint affi davit)

 Current mailing address                                                                       County

 City, state, ZIP code

Under penalties of perjury, I declare all of the following to be true:
1. I was not domiciled in Ohio at any time during taxable year 2015. Name of city (or cities), state(s) (if within the U.S.) and 
  country (if not within the U.S.) where I was domiciled.

2. I had at least one abode (place where I lived) outside of Ohio for the entire taxable year. Name of city (or cities), state(s) 
  (if within the U.S.) and country (if not within the U.S.) where I was domiciled. 

3. I had no more than 212 contact periods* in Ohio during the taxable year.
4. I       shall        shall not be fi ling a year 2015 Ohio individual income tax return.
Under penalties of perjury, I declare that to the best of my knowledge and belief the statements on this affi davit are true, 
correct and complete.
 
Signature        Date

Spouse’s signature (only if joint affi davit)     Date

* Ohio Revised Code section 5747.24(A)(1) states that an individual “has one contact period in this state” if the individual is away overnight from his/her 
 abode located outside this state and, while away overnight from that abode, spends at least some portion, however minimal, of each of two consecutive 
 days in this state.

                                                 Federal Privacy Act Notice
  Because we require you to provide us with a Social Security number, the Federal Privacy Act of 1974 requires us to inform 
  you that providing us with your Social Security number is mandatory. Ohio Revised Code sections 5703.05, 5703.057 and 
  5747.08 authorize us to request this information. We need your Social Security number in order to administer this tax. 

                            Please do not attach to, or enclose with, your Ohio income tax return.
                              Mail to: Ohio Department of Taxation, Attn: Line Item Review, 
                                               P.O. Box 182847, Columbus, OH 43218-2847
                                               Questions? Call us toll-free at 1-800-282-1780.

                                            IT DA Instructions
Who Should File This Affi davit?                                   43218-2847. The postmark date must be no later than May 
You must fi le this yearly affi davit if you meet either of the     31, 2016. Please do not attach this affi davit to, or enclose 
following criteria:                                               with, your Ohio individual income tax return.

  During the previous taxable year (2014) you fi led an Ohio      Whom Do I Contact if I Have Additional Questions 
   income tax return as a resident or part-year resident, and     About This Affi davit?
   for the current taxable year (2015) you are claiming to be     For faster service you can visit our Web site at tax.ohio.gov, 
   a nonresident/nondomiciliary.                                  click on “Contact” and electronically send us your question(s) 
                                                                  or you can call 1-800-282-1780.  
For the current taxable year (2015) you have no intent to       
   fi le an Ohio income tax return and you have (i) an abode       What Is the “Bright Line” Test Under Ohio Revised 
   in Ohio, (ii) a contact period in Ohio and/or (iii) nexus with Code Section 5747.24? 
   Ohio to the extent that the tax commissioner would have        This portion of Ohio law provides for a “bright line” test under 
   cause to question your nonfi ling.                              which an individual is presumed to be a full-year nonresident 
If you meet either of the criteria set forth above, but you do    if all of the following circumstances are present:
not fi le this affi davit by May 31, 2016, under Ohio law you         The individual has at least one abode outside Ohio for the 
are presumed to be a full-year domiciliary.                        entire year (the law does not defi ne “abode”),
Why Should I File This Affi davit?                                  The individual has no more than 212 contact periods in 
R.C.section 5747.24 requires that, in order to preserve the        Ohio, and
presumption of full-year non-Ohio residency, the taxpayer 
must fi le this affi davit by the 15th day of the fourth month       The individual timely submits to the Ohio Department of 
following the last day of the taxable year. However, R.C.          Taxation this affi davit, and the affi davit is not false.
section 5703.35 allows the tax commissioner to extend for 
45 days the due date for any report. As such, you must fi le       What Is a “Contact Period” in Ohio?
this tax return by May 31, 2016. The tax commissioner has         An individual has one contact period in this state if the 
no authority to extend beyond May 31, 2016 the due date           individual is away overnight from the individual’s abode 
for fi ling the year 2015 affi davit.                               located outside the state and while away overnight from 
                                                                  that abode spends at least some portion, however minimal, 
What Is the Due Date for Filing This Affi davit?                   of each of two consecutive days in this state. Note that the 
The postmark date must be no later than May 31, 2016.             individual does not have to spend the night in Ohio.  
Do I Need To File This Affi davit if I Have Not Earned or          For example: An individual who claims to be domiciled in 
Received Any Income in Ohio?                                      Florida has an abode in Florida for the entire year. On Jan. 
Even if you have no income that you earned or received in         2 of the taxable year the individual fl ies from Florida to 
Ohio, you must timely fi le this affi davit by May 31, 2016 if      Toledo.  Later on Jan. 2 the individual drives to Michigan 
you want to preserve the presumption of full-year non-Ohio        and spends the night in Michigan. On Jan. 3 the individual 
residency.                                                        drives from Michigan back to Ohio. Late in the day on Jan. 
                                                                  3 the individual fl ies from Toledo back to the individual’s 
If I Timely File Ohio Form IT DA, Do I Also Have To File          abode in Florida.  
Ohio Form IT 10, Information Notice of No Tax Due?
                                                                  The individual has one contact period in Ohio because the 
By fi ling Ohio form IT 10, you are indicating that you have no 
                                                                  individual spent some portion of two consecutive days (Jan. 2 
Ohio income tax liability. If you have not earned or received 
                                                                  and Jan. 3) in Ohio and was away overnight (from sometime 
any income in Ohio, you may want to consider fi ling both this 
                                                                  on Jan. 2 until sometime on Jan. 3) from the individual’s 
affi davit and Ohio form IT 10. Please do not mail the affi davit 
                                                                  abode in Florida.
and notice together since there is a different address for the 
affi davit and for the notice.                                     For more information regarding residency and contact 
                                                                  periods, see release IT 2015-02.
Where Do I Mail This Affi davit?
Please mail this affi davit to the Ohio Department of Taxation, 
Attn: Line Item Review, P.O. Box 182847, Columbus, OH