4190020105
                                                       (EX) 09-20 (FI)
                            REV-419                                   EMPLOYEE’S NONWITHHOLDING                                                           START
                                                                                APPLICATION CERTIFICATE                                                            Ü 20

                                    Please print or type. A fill-in form may be obtained from www.revenue.pa.gov. 

SECTION I                    EMPLOYEE INFORMATION
Employee Name: first, middle initial, last                                                                                                              Social Security Number     Telephone Number 

Street Address                                                       City                                            State          Zip Code            Tax Year (not necessary if checking Box b below)

SECTION II                   EXEMPTION INFORMATION
I claim exception from withholding because: 
              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. 
              b.   I declare I am a resident of the reciprocal state checked below: 
                            INDIANA                    MARYLAND                 NEW JERSEY                                        OHIO                    VIRGINIA                  WEST VIRGINIA 
                       and 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. 
              c.   I certify I am a legal resident of the state of                                                  and am not subject to Pennsylvania withholding because I meet the re-
              quirements set forth under the Servicemembers Civil Relief Act, as amended, and as set forth in revised Personal Income Tax Bulletin 2010-01.
SECTION III                  CERTIFICATION
Under 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 
liability during the current tax year based on the reason(s) indicated above.                                                                                        Example 08/15/2004
Employee Signature                                                                                                                                                                                        Date 
                                    PLEASE SIGN AFTER PRINTING.
Employer Name                                                                                                                                                    Federal Employer Identification Number 

Business Address                                                                                                                                                                                   Telephone Number 

City                                                                                                                                                                                        State                 Zip Code 

Employer’s Signature                                                                          Employee’s Quarterly Compensation (not required for applicants checking Box b or c above) 
                                                                                    $PLEASE SIGN AFTER PRINTING.

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                            4190020105                                                                                                                    4190020105

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                                                                Instructions for REV-419 
REV-419 IN (EX) 09-20                                    Employee’s Nonwithholding Application Certificate

                                                                Pennsylvania Personal Income Tax Return, and Schedule 
                      WHAT’S NEW                                SP to claim Tax Forgiveness even if they are eligible for non-
The form has been redesigned to meet the branding, for-         withholding. 
matting and instructions standards used for all department      Under the SCRA, as amended, you may be exempt from 
forms. The instructions and form have also been updated         PA personal income tax on your wages if (i) your spouse 
as a result of recent amendments to the federal Service-        is a member of the armed forces present in PA in compli-
members Civil Relief Act.                                       ance with military orders; (ii) you are present in PA solely 
                                                                to be with your spouse; and (iii) you and your spouse both 
         GENERAL INFORMATION                                    maintain domicile (state residency) in another state. If you 
                                                                claim exemption under the SCRA, enter your state of do-
PURPOSE OF FORM                                                 micile (legal residence) on Line d below and attach a copy 
Complete Form REV-419 so that your employer can with-           of your spousal military identification card and your 
hold the correct Pennsylvania personal income tax from          spouse’s current military orders to form REV-419. See 
your pay. Complete a new Form REV-419 every year or             Personal Income Tax Bulletin 2010-01 for additional 
when your personal or financial situation changes. Photo-       information. 
copies of this form are acceptable. 
                                                                RESPONSIBILITIES OF EMPLOYER 
NOTE: Unless the state of residence changes, res-               If you agree not to withhold PA tax because your employee 
idents of the reciprocal states listed in the next para-        is a resident of a reciprocal state, you must withhold the 
graph do not need to refile this application every year.        other state’s tax.   

         GENERAL INSTRUCTIONS                                   Retain Form REV-419 with your records. You are required 
                                                                to submit a copy of this certificate and accompanying attach-
WHO IS ELIGIBLE FOR NONWITHHOLDING?                             ments to the PA DEPARTMENT OF REVENUE, BUREAU 
You may be entitled to nonwithholding of PA personal in-        OF INDIVIDUAL TAXES, PO BOX 280507, HARRISBURG, 
come tax if you incurred no liability for income tax the pre-   PA 17128-0507, when: 
ceding tax year and/or you anticipate that you will incur no      1. You have reason to believe this certificate is incorrect; 
liability for income tax during the current tax year, according 
to the Special Tax Provisions of section 304 of the Tax Re-       2. The PA taxable gross compensation of any employee 
form Code, as a resident of the reciprocal state of Indiana,    who claimed exemption from nonwithholding on the 
Maryland, New Jersey, Ohio, Virginia or West Virginia and       form under Section II, Line a, exceeds $1,625 for any 
your employer agrees to withhold the income tax from that       quarter; 
state or as the spouse of an active duty service member 
under the Servicemembers Civil Relief Act (SCRA), as              3. The employee claims an exemption from withholding on 
amended.                                                        the basis of residence in a reciprocal state (Indiana, 
                                                                Maryland, New Jersey, Ohio, Virginia or West Virginia) 
WHEN TO CLAIM?                                                  and therefore, you agree to withhold income tax of the 
File this certificate with your employer as soon as you de-     employee’s state of residence; or  
termine you are entitled to claim nonwithholding. You must 
file a certificate each year you are eligible (see Note above     4. The employee claims an exemption from withholding 
for an exception). If you are employed by more than one em-     under the SCRA, as amended. 
ployer you must file a separate REV-419 with each em-           DEPARTMENT’S RESPONSIBILITY 
ployer. 
                                                                Upon receipt of any exemption application, the department 
RESPONSIBILITIES OF EMPLOYEES                                   will make a determination and notify the employer if a 
You must revoke this certification within 10 days from the      change is required. If the department disapproves the ap-
day you anticipate you will incur PA personal income tax li-    plication, the employer must immediately commence with-
ability for the current tax year. To discontinue or revoke this holding at the regular rate. Once a certificate is revoked by 
certification, submit notification in writing to your employer. the department, the employer must send any new applica-
Claimants who qualify for complete Tax Forgiveness under        tion received from the employee to the department for ap-
section 304 of the Tax Reform Code must file a PA-40,           proval before implementing the nonwithholding.

www.revenue.pa.gov                                                                                  REV-419      1
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