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                                 Nonresident Military Spouse
                                           Withholding Exemption

Part I - Information About the Employee
Legal last name                  Legal first name                          M.I.     Social Security Number

Address (number and street)

City or Post Office                                                        State    Zip code

Part II - Employee’s Certification: Wages are Exempt from Wisconsin’s Income Tax and Withholding

     I certify that:

     •           My spouse is a member of the armed forces and is present in Wisconsin in compliance with
                 military orders,

     •           I am present in Wisconsin solely to be with my spouse, and

     •           My wages are exempt from Wisconsin income tax and withholding because I qualify and choose
                 to make an election under 50 U.S.C. 4001(a)(3) to be a resident of                         .

Part III – Employee No Longer Qualifies for Exemption from Wisconsin’s Income Tax and Withholding

     I no longer qualify for the exemption under Part II as of                                        .
                                                                           Date (mm/dd/yyyy)

Part IV – Employe’s Signature
       Under penalties of perjury, I declare that the above information is true, correct, and complete to the 
       best of my knowledge and belief.
       Name                                                                                 Date
SIGN 
HERE 

Part V – Information About the Employer
Legal name                                                                  Employer Federal ID Number

Address (number and street)

City or Post Office                                                        State    Zip code

W-221 (R. 11-24)                                                                                Wisconsin Department of Revenue