Form It Da - Affidavit Of Non-Ohio Residency/domicile For Taxable Year 2011
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2IT DA
Rev. 9/11
Affi davit of Non-Ohio Residency/Domicile for Taxable Year 2011
This form is for use only by individuals who are claiming
to be full-year nonresidents for Ohio income tax purposes.
Due date: May 31, 2012. See Ohio Revised Code section 5747.24.
Who must fi le: Please see instructions.
Filing this affi davit does not exempt you from timely fi ling your Ohio income tax return for 2011 and paying any tax due.
First name
M.I.
Last name
Social Security no.
Spouse’s fi rst name
M.I.
Last name
Spouse’s Social Security no.
(only if joint affi davit)
(only if joint affi davit)
Address
County
City, state, ZIP code
Under penalties of perjury, I declare all of the following to be true:
1. I was not domiciled in Ohio at any time during taxable year 2011. I was domiciled in
(name of state(s) where domiciled).
2. I had at least one abode (place where I lived) outside of Ohio for the entire taxable year. Name of city (or cities), state(s)
(if within the U.S.) and country (if not within the U.S.) where I lived.
3. I had no more than 182 contact periods* in Ohio during the taxable year.
4. I
shall
shall not be fi ling a year 2011 Ohio individual income tax return.
Under penalties of perjury, I declare that to the best of my knowledge and belief the statements on this affi davit are true,
correct and complete.
Signature
Date
Spouse’s signature
Date
(only if joint affi davit)
* 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.
Federal Privacy Act Notice
Because we require you to provide us with a Social Security number, the Federal Privacy Act of 1974 requires us to inform
you that providing us with 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.
Please do not attach to, or enclose with, your Ohio income tax return.
Mail to: Ohio Department of Taxation, Attn: Correspondence and Line Item Review
4485 Northland Ridge Blvd., Columbus, OH 43229-5404
Questions? Call us toll-free at 1-800-282-1780.
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