Form 44-016 - Employee'S Statement Of Nonresidence In Iowa (2014)
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1Iowa Department of Revenue
Employee’s Statement of Nonresidence in Iowa
Employee’s Full Name
Social Security Number
I hereby declare, under penalty of
perjury, that I am a resident of the
Employee’s Address
state of Illinois and that, pursuant
to an agreement existing between
Employer’s Name
Employer’s Address
that state and the state of Iowa, I
claim exemption from withholding
Employer:
of Iowa income tax on
You are required to have a copy of this form on file for each employee who is a resident of
compensation paid to me in the
Illinois receiving compensation paid in Iowa and who claims exemption from withholding of
state of Iowa.
Iowa income tax under the reciprocal agreement between Iowa and Illinois.
Employee Signature:
Employee:
If you are a resident of Illinois, you may claim exemption from withholding of Iowa income
tax by completing this form and filing it with your employer, under the reciprocal agreement
___________________________
between Iowa and Illinois.
Date: _____/_____/_____
Note: If you change your state of residence, you must notify your employer within 10 days.
44-016 (07/22/14)
Iowa Department of Revenue
Employee’s Statement of Nonresidence in Iowa
Employee’s Full Name
Social Security Number
I hereby declare, under penalty of
perjury, that I am a resident of the
Employee’s Address
state of Illinois and that, pursuant
to an agreement existing between
Employer’s Name
Employer’s Address
that state and the state of Iowa, I
claim exemption from withholding
Employer:
of Iowa income tax on
You are required to have a copy of this form on file for each employee who is a resident of
compensation paid to me in the
Illinois receiving compensation paid in Iowa and who claims exemption from withholding of
state of Iowa.
Iowa income tax under the reciprocal agreement between Iowa and Illinois.
Employee Signature:
Employee:
If you are a resident of Illinois, you may claim exemption from withholding of Iowa income
tax by completing this form and filing it with your employer, under the reciprocal agreement
___________________________
between Iowa and Illinois.
Date:_____/_____/_____
Note: If you change your state of residence, you must notify your employer within 10 days.
44-016 (07/22/14)
Iowa Department of Revenue
Employee’s Statement of Nonresidence in Iowa
Employee’s Full Name
Social Security Number
I hereby declare, under penalty of
perjury, that I am a resident of the
Employee’s Address
state of Illinois and that, pursuant
to an agreement existing between
Employer’s Name
Employer’s Address
that state and the state of Iowa, I
claim exemption from withholding
Employer:
of Iowa income tax on
You are required to have a copy of this form on file for each employee who is a resident of
compensation paid to me in the
Illinois receiving compensation paid in Iowa and who claims exemption from withholding of
state of Iowa.
Iowa income tax under the reciprocal agreement between Iowa and Illinois.
Employee Signature:
Employee:
If you are a resident of Illinois, you may claim exemption from withholding of Iowa income
tax by completing this form and filing it with your employer, under the reciprocal agreement
___________________________
between Iowa and Illinois.
Date:_____/_____/_____
Note: If you change your state of residence, you must notify your employer within 10 days.
44-016 (07/22/14)
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