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
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.
Payroll Form 52A