42A809                                 COMMONWEALTH OF KENTUCKY, DEPARTMENT OF REVENUE
3-07                                                  FRANKFORT, KENTUCKY 40620                  See Instructions on Reverse
                                            CERTIFICATE OF NONRESIDENCE
(Please Type or Print)

Name of employee ____________________________________________________  Social Security No. _____________________________

Home address____________________________________________ _________________________ ________________ __________
                      Number and street or rural route                City, town, or post office State                               ZIP Code
I have not been a resident of Kentucky during the year. (Check block in front of applicable statement.) I work in Kentucky and reside in:
Illinois,             Indiana,              Michigan,  West Virginia, Wisconsin
Virginia and commute daily to my place of employment in Kentucky. (Must commute daily to apply.)
Ohio and I am not a shareholder-employee who is a “twenty (20) percent or greater” direct or indirect equity investor in a S corporation.
I hereby certify that the above information is true and complete. I further certify that at any time I change my status as a resident
of_________________________________ , I will notify my employer of such fact within ten days from date of change.
     Name of current state of residence
_______________________________________________                                                          _________________________________________
                      Signature of employee                                                      Date

                                                   INSTRUCTIONS
                                                   To Be Filed With Employer

To The Employee:
You are exempt from income taxes on wages or salaries earned in Kentucky if: (1) You have not been a resident of Kentucky during the taxable year
and you reside in Illinois, Indiana, Michigan, West Virginia, or Wisconsin or (2) you reside in Virginia and commute daily to your place of
employment in Kentucky or (3) you reside in Ohio and are not a shareholder-employee who is a “twenty (20) percent or greater” direct or indirect
equity investor in a S corporation.
If you meet one of the above qualifications and are therefore exempt, your employer may cease withholding Kentucky income taxes. However, you
must complete the front of this form and file it with your employer before he can stop withholding.

To The Employer:
Upon receipt of this form, properly completed, you are authorized to discontinue the withholding of Kentucky income tax from the wages of (1) an
employee who resides in Illinois, Indiana, Michigan, West Virginia, or Wisconsin, and has not resided in Kentucky during the taxable year, or (2) an
employee who resides in Virginia and commutes daily to his place of employment in Kentucky or (3) an employee who resides in Ohio and is not
a shareholder-employee who is a “twenty (20) percent or greater” direct or indirect equity investor in a S corporation. The completed form is to be
retained in your file. If the employee moves or otherwise changes his residence to a state other than those mentioned above, begin withholding
Kentucky income tax, as required by KRS 141.310, with the first payroll period ending after you receive notice of status change from the employee.