Department of Taxation and Finance
                                                                                                                      IT-2104-IND
                                                                                                                                          (8/15)
                                               New York State Certificate of
                                               Exemption from Withholding
               First name and middle initial       Last name                                                Social security number

   Home address (number and street or rural route)                                                                        Apartment number

 Print or type   City, village, or post office                                                        State                ZIP code

 Employee’s certification – This is to certify that I am an enrolled member of the
 Indian tribe/nation and that I live on and my income is earned from employment on the
 Indian Reservation.
 I will notify my employer within 10 days of any change in my status.
  Employee’s signature                                                                                                Date

To be used only by a Native American who is not subject to New York State income tax (see instructions on back).

IT-2104-IND (8/15) (back)                                         Instructions

Employee                                                                         Employer 
If you are an enrolled member of a tribe or nation recognized by                 Do not withhold New York State tax from the wages of 
the United States or by New York State, and you are a Native                     employees who qualify and file this certificate with you. If the 
American who works and lives on that tribe’s reservation, you                    employee’s status changes, you must begin to withhold New 
are not subject to state tax on income earned on the reservation.                York State tax.
If you qualify, file this certificate with your employer and your 
employer will not withhold New York State tax from your wages.                   Keep this form with your records; do not send it to the New York 
                                                                                 State Tax Department.
A penalty of $500 may be imposed for providing false 
information that decreases your withholding amount.                              Privacy notification
                                                                                 See our Web site or Publication 54, Privacy Notification.

                                                                                                                           www.tax.ny.gov