Illinois Employee's Statement of Nonresidence in Illinois

Employee's Statement of Nonresidence in Illinois
IL-W-5-NR, Employee’s Statement of Nonresidence in Illinois
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Illinois Department of Revenue

IL-W-5-NR Employee’s Statement of Nonresidence in Illinois

Must I complete this form?

To employers:

You must complete Part 1 of this form if
•	 you are a resident of Iowa, Kentucky, Michigan, or Wisconsin, or
•	 your spouse is in the military, you and your spouse are both residents of
the same state (other than Illinois) and you are in Illinois only because
your spouse is stationed here by the military,
and your wages are exempt from withholding of Illinois Income Tax under the
reciprocal withholding agreements between Illinois and these states or under
the Military Spouses Residency Relief Act. You must file your completed Form
IL-W-5-NR with your Illinois employer. If you change your state of residence,
you must notify your employer within ten days.

You are required to have a copy of this form on file for each employee who
•	 is a resident of Iowa, Kentucky, Michigan, or Wisconsin; receives compensation paid in Illinois; and elects to claim exemption from withholding of Illinois Income Tax under the reciprocal withholding agreements
between Illinois and these states, OR
•	 is exempt from Illinois Income Tax on compensation under the Military
Spouses Residency Relief Act.	

Part 1: Employee information

Part 2: Employer information

_____ ______ _____ - _____ _____ - _____ _____ _____ _____
Social Security number	

_____ _____ - _____ _____ _____ _____ _____ _____ _____
	

Federal employer identification number

______________________________________________________________________
Name

______________________________________________________________________
Name

______________________________________________________________________
Mailing address	
	

______________________________________________________________________
Mailing address	
	

______________________________________________________________________
City		
State	
ZIP

______________________________________________________________________
City		
State	
ZIP

I declare under penalties of perjury that
	 I am a resident of the state of:
	 Iowa
Kentucky
Michigan
Wisconsin, OR
	 My spouse and I are residents of (write the 2-letter abbreviation for your
state of residency) ____ and I am in Illinois only because my spouse is a member of the US military who is stationed in Illinois.
______________________________________________________________________
Employee’s signature

Date

IL-W-5-NR (R-12/10)

Reset

This form is authorized under the Illinois Income Tax Act. Disclosure of this information is required.
Failure to provide information may result in this form not being processed and may result in a penalty.

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