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A fill-in form may be obtained [from](from www.revenue.pa.gov)[ www.revenue.pa.gov](from www.revenue.pa.gov).  \n\n| SECTION I | EMPLOYEE INFORMATION |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Employee Name: first, middle initial, last |  |  |  |  | Social Security Number | Telephone Number |\n| Street Address |  | City | State | Zip Code | Tax Year (not necessary if checking Box b below) |  |\n\n\n| SECTION II | EXEMPTION INFORMATION |\n| --- | --- |\n\nI claim exception from withholding because:  \n a. I qualified for Tax Forgiveness of my PA personal income tax liability last year, and had a right to a full refund of all income tax withheld and/or I expect to qualify for Tax Forgiveness of my PA personal income tax liability this year and expect to have a right to a full refund of all income tax withheld.  \n b. I declare I am a resident of the reciprocal state checked below:  \n INDIANA  MARYLAND  NEW JERSEY  OHIO  VIRGINIA  WEST VIRGINIA  \nand that pursuant to the reciprocal tax agreement between that state and PA, I claim an exemption from withholding of PA personal income tax and authorize my employer to withhold income tax for my resident state on compensation paid to me in the Commonwealth of Pennsylvania.  \n c. I certify I am a legal resident of the state of   and am not subject to Pennsylvania withholding because I meet the requirements set forth under the Servicemembers Civil Relief Act, as amended , and as set forth in revised Personal Income Tax Bulletin 2010-01.  \n\n| SECTION III | CERTIFICATION |\n| --- | --- |\n\nUnder penalties of perjury, I certify that I did not incur any Pennsylvania personal income tax liability during the preceding tax year and/or I do not expect to incur any  \nliability during the current tax year based on the reason(s) indicated above. Example 08/15/2004  \n\n| Employee Signature\u003Cbr>\u003Cbr>PLEASE SIGN AFTER PRINTING. |  |  |  |  |  | Date |\n| --- | --- | --- | --- | --- | --- | --- |\n| Employer Name |  | Federal Employer Identification Number |  |  |  |  |\n| Business Address |  |  |  | Telephone Number |  |  |\n| City |  |  | State |  | Zip Code |  |\n| Employer’s Signature\u003Cbr>\u003Cbr>PLEASE SIGN AFTER PRINTING. | Employee’s Quarterly Compensation (not required for applicants checking Box b or c above)$ |  |  |  |  |  |\n\nReset Entire Form  \nPRINT FORM  \n4190020105  \n4190020105  \nInstructions for REV-419  \nREV-419 IN (EX) 03-24 Employee’s Nonwithholding Application Certificate  \n\n| \u003Cbr>WHAT’S NEW\u003Cbr>The form has been redesigned to meet the branding, formatting and instructions standards used for all department forms. The instructions and form have also been updated as a result of recent amendments to the federal Servicemembers Civil Relief Act.\u003Cbr>\u003Cbr>GENERAL INFORMATION\u003Cbr>PURPOSE OF FORM\u003Cbr>Complete Form REV-419 so that your employer can withhold the correct Pennsylvania personal income tax from your pay. Complete a new Form REV-419 every year or when your personal or financial situation changes. Photocopies of this form are acceptable.\u003Cbr>NOTE: Unless the state of residence changes, res\u003Cbr>idents of the reciprocal states listed in the next paragraph do not need to refile this application every year.\u003Cbr>\u003Cbr>\u003Cbr>GENERAL INSTRUCTIONS\u003Cbr>WHO IS ELIGIBLE FOR NONWITHHOLDING?\u003Cbr>You may be entitled to nonwithholding of PA personal income tax if you incurred no liability for income tax the preceding tax year and/or you anticipate that you will incur no liability for income tax during the current tax year, according to the Special Tax Provisions of section 304 of the Tax Reform Code, as a resident of the reciprocal state of Indiana, Maryland, New Jersey, Ohio, Virginia or West Virginia and your employer agrees to withhold the income tax from that state or as the spouse of an active duty service member under the Servicemembers Civil Relief Act (SCRA), as amended.\u003Cbr>WH","cbCaiaExVXSOaRen","https://ap.wps.com/l/cbCaiaExVXSOaRen","pdf",435329,"English","# SECTION I: EMPLOYEE INFORMATION\n# SECTION II: EXEMPTION INFORMATION\n# SECTION III: CERTIFICATION\n# INSTRUCTIONS FOR REV-419\n## PURPOSE OF FORM\n## GENERAL INSTRUCTIONS\n## WHO IS ELIGIBLE FOR NONWITHHOLDING?\n## WHEN TO CLAIM?\n## RESPONSIBILITIES OF EMPLOYEES\n## RESPONSIBILITIES OF EMPLOYER","[{\"question\":\"What is the purpose of Form REV-419?\",\"answer\":\"Complete REV-419 so an employer withholds the correct Pennsylvania personal income tax from your pay, or applies nonwithholding when you meet the eligibility conditions.\"},{\"question\":\"When should an employee file REV-419 and does it need to be filed every year?\",\"answer\":\"File the certificate as soon as you determine you are entitled to claim nonwithholding. You must file each year you are eligible, with a note that residents of listed reciprocal states generally do not need to refile unless their residence state changes.\"},{\"question\":\"What information and documentation may be required for exemptions?\",\"answer\":\"Choose the basis for your exemption in Section II (tax forgiveness, reciprocal state residency, or an SCRA-related situation). For an SCRA-based exemption, enter your state of domicile on Line c and attach a copy of your spouse’s military identification card and your spouse’s current military orders.\"}]","REV-419 Employee’s Nonwithholding Application Certificate | PDF",1789794003]