Government of the                     Form D-4A Certi ficate of Nonresidence in the District of Columbia 
      District of Columbia
                             Enter Year
First name                                        M.I.  Last name

Temporary DC address (number and street)                                                 Social security number 

Permanent address (number and street)                                                    Apartment number 

City                                                                  State Zip code + 4 

Country or U.S. commonwealth 

Signature   Under penalties of law, I certify that my permanent residence is not in DC and that I will not be residing in DC for 183 days or more in the tax year.
  Signature                                           Date
                                                                                                                Revised 12/2016

Instructions 
Who must  fi le a Form D-4A?                                    What if your resident status changes?
If you are not a resident of DC you must fi le a Form D-4A      If you become a DC resident any time after you have fi led 
with your employer to establish that you are not subject to DC a Form D-4A with your employer, you must fi le a Form D-4  
income tax withholding. You qualify as a nonresident if:       promptly so that the proper amount of DC income tax can be 
• Your permanent residence is outside DC during all of         withheld from your wages.
the tax year andyou do not reside in DC for 183 days or        How do you  file the Form D-4?
more in the tax year.                                          After completing this form, give it to your employer to keep 
• You are a service member’s spouse.                           on fi le.
Employees who are residents of DC should fi le a Form D-4,
DC Withholding Allowance Certifi cate.