New Jersey Employee's Certificate of Non-Residence In New Jersey

Employee's Certificate of Non-Residence In New Jersey
Employee’s Certificate of Nonresidence In New Jersey, Form NJ-165
NJ-165
9-19

STATE OF NEW JERSEY
Department of the Treasury
Division of Taxation
PO Box 269
Trenton, NJ 08695-0269

Employee’s Certificate of Nonresidence In New Jersey
Print or Type

First Name	

MI	

Last Name

Social Security Number

Street Address

City	

State	

ZIP Code

Pennsylvania Residents
I hereby declare, under penalties of perjury, that I am a resident of the State of Pennsylvania and that, pursuant to a reciprocal
agreement existing between that State and the State of New Jersey, I claim exemption from withholding of New Jersey Gross
Income Tax on compensation paid to me in the State of New Jersey and authorize my employer to withhold Pennsylvania
personal income taxes on my behalf.
Note: If you change your residence from Pennsylvania to any other state, you must notify your employer within 10 days.

	Date	

	

Signature

Military Spouses
Under the Servicemember Civil Relief Act (SCRA), as amended by the Military Spouses Residency Relief Act, you may be
exempt from New Jersey Income Tax on your wages if you reside in New Jersey but have chosen a state other than New Jersey
as your legal residence. If you claim exemption under the SCRA, attach a copy of your spousal military identification card to
Form NJ-165.
I certify that I am not subject to New Jersey withholding. I meet the conditions set forth under the Servicemember Civil Relief Act,
as amended by the Military Spouses Residency Relief Act.

	Date	

	

Signature

New Jersey Employer
You are required to have a copy of this form on file for each employee receiving compensation paid in New Jersey and who
is a resident of Pennsylvania and claims exemption from withholding of New Jersey Gross Income Tax under the reciprocal
agreement between New Jersey and Pennsylvania or who claims exemption from withholding of New Jersey Gross Income Tax
under the Servicemember Civil Relief Act, as amended by the Military Spouses Residency Relief Act. Do not forward this Form
to the Division of Taxation.

This Form May Be Reproduced
Do Not Forward This Form To The Division of Taxation