Letter of Residence Certificate

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Letter of Residence Certificate Powered By Docstoc
					                                               PURDUE UNIVERSITY
                                                      PAYROLL DEPARTMENT
                                                        401 S. Grant Street
                                                  WEST LAFAYETTE, IN 47907-1064



                                         CERTIFICATE OF RESIDENCE
                      FOR EMPLOYEES WHO NEITHER WORK NOR RESIDE IN INDIANA


        1)     My Name is:

        2)     Social Security Number

        3)     My Home State Resident Address is:




               My Employment Address is:




        4)     I do not own personal property in Indiana, and income from salaries, wages, and commissions
               received from Indiana sources are taxable in my state of residence and not subject to the Indiana
               Income Tax based on the fact that I neither reside nor work in Indiana.

        5)     I am requesting that Purdue University not withhold Indiana Adjusted Gross Income Tax or County
               Income Tax from my salary payments.

        6)     I understand that to be exempt from the County Adjusted Gross Income Tax (CAGIT), County
               Economic Development Income Tax (CEDIT), or County Option Income Tax (COIT) I must file
               an Indiana Withholding Exemption and County Residence Certificate (WH-4) must be filed
               indicating that my County of residence and principal work activity are out of state.

        7)     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.

        8)     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.

        9)     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
Purdue University

Payroll Form 52A

				
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