NJ-165
9-19

                                      STATE OF NEW JERSEY
                                      Department of the Treasury
                                      Division of Taxation
                                      PO Box 269
                                      Trenton, NJ 08695-0269

                            Employee’s Certificate of Nonresidence In New Jersey
Print or Type
First Name                         MI Last Name                          Social Security Number

Street Address

City                                                      State                                    ZIP Code

                                      Pennsylvania Residents
I hereby declare, under penalties of perjury, that I am a resident of the State of Pennsylvania and that, pursuant to a reciprocal 
agreement existing between that State and the State of New Jersey, I claim exemption from withholding of New Jersey Gross 
Income Tax on compensation paid to me in the State of New Jersey and authorize my employer to withhold Pennsylvania 
personal income taxes on my behalf.
Note: If you change your residence from Pennsylvania to any other state, you must notify your employer within 10 days.

             Date                                               Signature

                                      Military Spouses
Under the Servicemember Civil Relief Act (SCRA), as amended by the Military Spouses Residency Relief Act, you may be 
exempt from New Jersey Income Tax on your wages if you reside in New Jersey but have chosen a state other than New Jersey 
as your legal residence. If you claim exemption under the SCRA, attach a copy of your spousal military identification card to 
Form NJ-165.
I certify that I am not subject to New Jersey withholding. I meet the conditions set forth under the Servicemember Civil Relief Act,
as amended by the Military Spouses Residency Relief Act.

             Date                                               Signature

                                      New Jersey Employer
You are required to have a copy of this form on file for each employee receiving compensation paid in New Jersey and who 
is a resident of Pennsylvania and claims exemption from withholding of New Jersey Gross Income Tax under the reciprocal 
agreement between New Jersey and Pennsylvania or who claims exemption from withholding of New Jersey Gross Income Tax 
under the Servicemember Civil Relief Act, as amended by the Military Spouses Residency Relief Act. Do not forward this Form 
to the Division of Taxation.

                                      This Form May Be Reproduced
                            Do Not Forward This Form To The Division of Taxation