STATE OF NEW JERSEY
Department of the Treasury
Division of Taxation
PO Box 269
Trenton, NJ 08695-0269
EMPLOYEE’S CERTIFICATE OF NON-RESIDENCE IN NEW JERSEY
(To Be Used By Pennsylvania Residents only)
Print or Type
First Name MI Last Name Social Security No.
Street Address
City State Zip Code
Note: If you change your residence from Pennsylvania 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 Pennsylvania and that, pursuant
to an agreement existing between that State and the State of New Jersey, I claim exemption from withholding
of New Jersey Gross Income Tax on compensation paid to me in the State of New Jersey and authorize my
employer to withhold Pennsylvania Personal Income Taxes on my behalf.
__________________________ ____________________________________________________
(Date) (Signature)
NEW JERSEY EMPLOYER:
You are required to have a copy of this form on file for each employee receiving compensation paid in New
Jersey and who is a resident of Pennsylvania and claims exemption from withholding of New Jersey Gross
Income Tax under the reciprocal agreement entered into between New Jersey and Pennsylvania.
MAY BE REPRODUCED
NJ-165
4-03, R-4
