DR 1059 (09/26/19) 
                                                   COLORADO DEPARTMENT OF REVENUE 
                                                   Denver CO  80261-0005
*131059==19999*

                       Affidavit of Exemption for the Nonresident
                                    Spouse of a U.S. Servicemember
Servicemember’s Spouse
Last Name                                                 First Name                                             Middle Initial

SSN                                                                      State of Residence

Servicemember
Last Name                                                 First Name                                             Middle Initial

SSN                                                                      State of Residence

Permanent Duty Station                                                                                           Calendar Year

Purpose of This Affidavit                                                If these conditions are met, the spouse’s wages are exempt from 
The nonresident  spouse  of a servicemember  may provide  a  Colorado income tax and wage withholding tax.
completed  copy  of  this  affidavit,  along  with  a  copy  of  his  or 
                                                                         “Servicemember” Definition and Residency
her dependent  ID card issued  by the applicable  branch  of the 
                                                                         A  “servicemember” is  a  member of  the Army,  Navy, Air  Force, 
uniformed  services, to the nonresident spouse’s employer  to 
                                                                         Marine Corps, Coast Guard or the commissioned corps of either 
attest to his or her eligibility for exemption from Colorado wage 
                                                                         the National  Oceanic and  Atmospheric  Administration  or the 
withholding. An employer who has received a properly completed 
affidavit from an employee is relieved of the obligation to withhold     Public Health Service.
Colorado  income tax  from the employee’s  pay.  The employer            A servicemember who is not a Colorado resident does not become 
should not submit the affidavit to the Department of Revenue, but        a Colorado resident simply because they are in Colorado solely in 
rather the employer must retain the affidavit in their records and       compliance with military orders.
provide a copy of it to the Department only upon request.                Residency of a Servicemember’s Spouse
If a servicemember’s spouse is required to file a Colorado income tax  A servicemember’s spouse may elect, for income tax purposes, 
return, a copy of this affidavit, along with a copy of his or her dependent  to use the same state of residence as the servicemember. If a 
ID card, must be submitted with his or her Colorado income tax return.   servicemember  is not a Colorado  resident,  and  is instead  a 
Colorado Income Tax and Wage Withholding Tax Exemption                   resident of another state, his or her spouse can elect to also be a 
Federal law 50 U.S.C. § 4001(c) precludes Colorado from taxing  resident of that state and not a resident of Colorado. Additionally, 
the income earned by the spouse of a servicemember for services  if a servicemember and his or her spouse have as their shared 
performed within Colorado if both:                                       state of residence a state other than Colorado, the spouse also 
•  the spouse is not a resident of Colorado; and                         does not become a Colorado resident simply because he or she 
•  the spouse is in Colorado solely to be with the                       is in Colorado solely to be with the servicemember who is serving 
    servicemember serving in compliance with military orders.            in compliance with military orders.
Attestation by Servicemember’s Spouse                                                                            Initial
1. I am not a resident of Colorado, based upon the conditions described above.

2. My spouse is a servicemember, as defined above.

3. My spouse is not a Colorado resident, based upon the conditions described above.

4. I am in Colorado solely to be with my spouse, who is serving in compliance with military orders.

5. I will notify my employer immediately if I become a Colorado resident.
I hereby attest that, to the best of my knowledge and belief, the foregoing statements are true, accurate, and complete and the wages I earn 
from services performed in Colorado are therefore exempt from Colorado income and wage withholding tax.
Signature of Servicemember’s Spouse                                                                              Date (MM/DD/YY)