Pennsylvania Employee's Nonwithholding Application Certificate

Employee's Nonwithholding Application Certificate
Employee's Nonwithholding Application Certificate (REV-419)
4190020105
(EX) 09-20 (FI)

REV-419

EMPLOYEE’S NONWITHHOLDING
APPLICATION CERTIFICATE

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Please print or type. A fill-in form may be obtained from www.revenue.pa.gov.

EMPLOYEE INFORMATION

SECTION I

Employee Name: first, middle initial, last

Social Security Number

Street Address

City

State

Zip Code

Telephone Number

Tax Year (not necessary if checking Box b below)

EXEMPTION INFORMATION

SECTION II

I claim exception from withholding because:
a. I qualified for Tax Forgiveness of my PA personal income tax liability last year, and had a right to a full refund of all income tax withheld and/or
I expect to qualify for Tax Forgiveness of my PA personal income tax liability this year and expect to have a right to a full refund of all income tax
withheld.
b. I declare I am a resident of the reciprocal state checked below:
INDIANA
MARYLAND
NEW JERSEY
OHIO
VIRGINIA
WEST VIRGINIA
and that pursuant to the reciprocal tax agreement between that state and PA, I claim an exemption from withholding of PA personal income tax and
authorize my employer to withhold income tax for my resident state on compensation paid to me in the Commonwealth of Pennsylvania.
c. I certify I am a legal resident of the state of
and am not subject to Pennsylvania withholding because I meet the requirements set forth under the Servicemembers Civil Relief Act, as amended, and as set forth in revised Personal Income Tax Bulletin 2010-01.

CERTIFICATION

SECTION III

Under penalties of perjury, I certify that I did not incur any Pennsylvania personal income tax liability during the preceding tax year and/or I do not expect to incur any
liability during the current tax year based on the reason(s) indicated above.
Example 08/15/2004
Employee Signature

Date

PLEASE SIGN AFTER PRINTING.
Employer Name

Federal Employer Identification Number

Business Address

Telephone Number

City

State

Employer’s Signature

PLEASE SIGN AFTER PRINTING.

Reset Entire Form

4190020105

Zip Code

Employee’s Quarterly Compensation (not required for applicants checking Box b or c above)

$

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4190020105

Instructions for REV-419

Employee’s Nonwithholding Application Certificate

REV-419 IN (EX) 09-20

WHAT’S NEW
The form has been redesigned to meet the branding, formatting and instructions standards used for all department
forms. The instructions and form have also been updated
as a result of recent amendments to the federal Servicemembers Civil Relief Act.

GENERAL INFORMATION
PURPOSE OF FORM
Complete Form REV-419 so that your employer can withhold the correct Pennsylvania personal income tax from
your pay. Complete a new Form REV-419 every year or
when your personal or financial situation changes. Photocopies of this form are acceptable.
NOTE: Unless the state of residence changes, residents of the reciprocal states listed in the next paragraph do not need to refile this application every year.

GENERAL INSTRUCTIONS
WHO IS ELIGIBLE FOR NONWITHHOLDING?
You may be entitled to nonwithholding of PA personal income tax if you incurred no liability for income tax the preceding tax year and/or you anticipate that you will incur no
liability for income tax during the current tax year, according
to the Special Tax Provisions of section 304 of the Tax Reform Code, as a resident of the reciprocal state of Indiana,
Maryland, New Jersey, Ohio, Virginia or West Virginia and
your employer agrees to withhold the income tax from that
state or as the spouse of an active duty service member
under the Servicemembers Civil Relief Act (SCRA), as
amended.
WHEN TO CLAIM?
File this certificate with your employer as soon as you determine you are entitled to claim nonwithholding. You must
file a certificate each year you are eligible (see Note above
for an exception). If you are employed by more than one employer you must file a separate REV-419 with each employer.
RESPONSIBILITIES OF EMPLOYEES
You must revoke this certification within 10 days from the
day you anticipate you will incur PA personal income tax liability for the current tax year. To discontinue or revoke this
certification, submit notification in writing to your employer.
Claimants who qualify for complete Tax Forgiveness under
section 304 of the Tax Reform Code must file a PA-40,

www.revenue.pa.gov

Pennsylvania Personal Income Tax Return, and Schedule
SP to claim Tax Forgiveness even if they are eligible for nonwithholding.
Under the SCRA, as amended, you may be exempt from
PA personal income tax on your wages if (i) your spouse
is a member of the armed forces present in PA in compliance with military orders; (ii) you are present in PA solely
to be with your spouse; and (iii) you and your spouse both
maintain domicile (state residency) in another state. If you
claim exemption under the SCRA, enter your state of domicile (legal residence) on Line d below and attach a copy
of your spousal military identification card and your
spouse’s current military orders to form REV-419. See
Personal Income Tax Bulletin 2010-01 for additional
information.
RESPONSIBILITIES OF EMPLOYER
If you agree not to withhold PA tax because your employee
is a resident of a reciprocal state, you must withhold the
other state’s tax.
Retain Form REV-419 with your records. You are required
to submit a copy of this certificate and accompanying attachments to the PA DEPARTMENT OF REVENUE, BUREAU
OF INDIVIDUAL TAXES, PO BOX 280507, HARRISBURG,
PA 17128-0507, when:
1. You have reason to believe this certificate is incorrect;
2. The PA taxable gross compensation of any employee
who claimed exemption from nonwithholding on the
form under Section II, Line a, exceeds $1,625 for any
quarter;
3. The employee claims an exemption from withholding on
the basis of residence in a reciprocal state (Indiana,
Maryland, New Jersey, Ohio, Virginia or West Virginia)
and therefore, you agree to withhold income tax of the
employee’s state of residence; or
4. The employee claims an exemption from withholding
under the SCRA, as amended.
DEPARTMENT’S RESPONSIBILITY
Upon receipt of any exemption application, the department
will make a determination and notify the employer if a
change is required. If the department disapproves the application, the employer must immediately commence withholding at the regular rate. Once a certificate is revoked by
the department, the employer must send any new application received from the employee to the department for approval before implementing the nonwithholding.

REV-419
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