City of Columbus, Income Tax Division

Employee's Withholding Exemption Certificate 
To be used by those meeting the requirements of  
The Military Spouses Residency Relief Act
                                                                                (Form must be completed annually)
Part 1    ACCOUNT INFORMATION
Social Security Number               First Name    Middle Initial               Last Name

Address                                                                         County (First 5 letters)

City                                 State         Zip Code                     Country (if not U.S.)

Part 2    CERTIFICATION INFORMATION

        I certify that I am not subject to City of Columbus, Ohio withholding because I meet the requirements 
        of the Military Spouses Residency Relief Act and I am legally domiciled in:
             State                   City/Township                                                      For the Year

        I have attached copies of: 
                   •   DD Form 2058 (State of Legal Residence Certificate) 
                   •   My Spousal military ID card 
                   •   The service ember's most recent leave and earnings statement 
         
        I certify that I no longer meet the requirements for exemption under the Military Spouses Residency 
        Relief Act.  Therefore, I revoke my exemption and request that my employer withhold City of 
        Columbus income tax.

CAUTION:  If you furnish an employer with an Employee's Withholding Exemption Certificate that contains 
information with no basis resulting in no tax being withheld when it in fact should have been withheld, you are 
subject to penalty and interest in addition to the amount not properly withheld.

I certify, under penalties provided by law, that I am entitled to exempt status.
 
_________________________________________________________________ 
Employee's Signature                                                                Date

Part 3  EMPLOYER SIGNATURE
(Employer:  Complete below and submit original to City of Columbus, Withholding Tax Section.  Keep a copy for your records.
Employer Name                                                                   EIN/FID

Employer Address                                                                County (First 5 letters)

City                                 State         Zip Code                     Country (if not U.S.)

Rev. 12/21/18
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