Form It Da-Nm - Affidavit Of Non-Ohio Domicile For Taxable Years 2006 And Prior - Nonmilitary
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1IT DA-NM
Rev. 6/07
Reset Form
Affidavit of Non-Ohio Domicile for Taxable Years 2006 and Prior – Nonmilitary
This form is nonmilitary only.
First name
Initial
Last name
Soc. Sec. no.
Filing status – check
only one
If joint affidavit, spouse’s first name
Initial
Spouse’s last name
Spouse’s Soc. Sec. no.
Single or head of
household or
qualifying widow(er)
Address
Ohio county
Married filing jointly
City, state, ZIP code
Married filing
separately
Domicile (Residency) Affidavit for Taxable Year
Under penalties of perjury, I declare all of the following to be true:
1. I was not domiciled in Ohio at any time during the taxable year set forth above. I was domiciled in
(name of state(s) where domiciled).
2. I had at least one abode (place where I lived) outside Ohio for the entire taxable year
(name of state(s) where I lived if different from question 1).
3. I have spent less than 120 contact periods* in Ohio during the taxable year.
Your signature
Date
If joint affidavit, spouse’s signature
Date
* Ohio Revised Code section 5747.24(A)(1) states that an individual “has one contact period in this state” if the individual is
away overnight from his/her abode located outside this state and, while away overnight from that abode, spends at least
some portion, however minimal, of each of two consecutive days in this state. Further, Ohio Revised Code section 5747.24(A)(2)
provides that up to 30 periods that would otherwise constitute contact periods under division (A)(1)(a) of this section shall not
be considered contact periods during a taxable year if the individual spends any portion of either day of each such contact
period for conditions outlined in Ohio Revised Code sections 5747.24(A)(2)(a).
Federal Privacy Act Notice
Because we require you to provide us with a social security account number,
the Federal Privacy Act of 1974 requires us to inform you that your providing
us your Social Security number is mandatory. Ohio Revised Code sections
5703.05, 5703.057 and 5747.08 authorize us to request this information. We
need your Social Security number in order to administer this tax. Your failure
to supply any information requested on this affidavit will result in our inability
to process this document.
Please attach this affidavit to your Ohio form IT 1040 or IT 1040X. Indicating that you are not an Ohio resident may impact the
ability for you and/or your family members to obtain in-state tuition at an Ohio university, your ability to vote in Ohio, obtain or
keep an Ohio driver’s license, etc.
Questions? Call us toll-free at 1-800-282-1780.
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