Form Nj-165 - Employee'S Certificate Of Non-Residence In New Jersey - 1999
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1STATE OF NEW JERSEY
STATE OF NEW JERSEY
Department of the Treasury
Department of the Treasury
Division of Taxation
Division of Taxation
PO Box 269
PO Box 269
Trenton, NJ 08695-0269
Trenton, NJ 08695-0269
EMPLOYEE’S CERTIFICATE OF NON-RESIDENCE IN NEW JERSEY
EMPLOYEE’S CERTIFICATE OF NON-RESIDENCE IN NEW JERSEY
(To Be Used By Pennsylvania Residents only)
(To Be Used By Pennsylvania Residents only)
Print or Type
Print or Type
First Name
MI
Last Name
Social Security No.
First Name
MI
Last Name
Social Security No.
Street Address
Street Address
City
State
Zip Code
City
State
Zip Code
Note: If you change your residence from Pennsylvania to any other state, you must notify your
Note: If you change your residence from Pennsylvania to any other state, you must notify your
employer within 10 days.
employer within 10 days.
I hereby declare, under penalties of perjury, that I am a resident of the State of Pennsylvania and
I hereby declare, under penalties of perjury, that I am a resident of the State of Pennsylvania and
that, pursuant to an agreement existing between that State and the State of New Jersey, I claim
that, pursuant to an 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
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
State of New Jersey and authorize my employer to withhold Pennsylvania Personal Income Taxes
on my behalf.
on my behalf.
__________________________
_________________________________________
__________________________
_________________________________________
(Date)
(Signature)
(Date)
(Signature)
Employer’s Name
Federal ID Number
NEW JERSEY EMPLOYER:
Address
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 entered into between New Jersey and Pennsylvania.
Copy 2 - Division of Taxation Copy - Mail to the New Jersey Division of Taxation on
or before the 15th day of the month following its completion by your
employee.
Copy 1 - Employer’s Copy - To be retained in employer’s file
MAY BE REPRODUCED
MAY BE REPRODUCED
NJ-165
NJ-165
11-99, R-3
11-99, R-3
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