Form Nj-165 - Employee'S Certificate Of Non-Residence In New Jersey
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1
2STATE OF NEW JERSEY
Department of the Treasury
Division of Taxation
PO Box 269
Trenton, NJ 08646-0269
EMPLOYEE’S CERTIFICATE OF NON-RESIDENCE IN NEW JERSEY
(To Be Used by Pennsylvania Residents Only)
Print or Type
First Name
MI
Last Name
Social Security No.
Street Address
City
State
Zip Code
NOTE: If you change your residence from Pennsylvania to any other State, you must
notify your employer within 10 days.
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 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.
________________________
__________________________________________
(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 entered into between New Jersey and Pennsylvania.
Copy 1 - Employer’s Copy - To be retained in Employer’s File
MAY BE REPRODUCED
NJ-165
(9-97, R-3)
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Parent category: Financial