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

SECTION I   EMPLOYEE INFORMATION
Employee Name: first, middle initial, last
Social Security Number
Telephone Number
Street Address
City
State
Zip Code
Tax Year (not necessary if checking Box b below)
SECTION II    EXEMPTION INFORMATION

   I claim exception from withholding because:

SECTION III   CERTIFICATION
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.
Employee Signature
Date
Employer Name
Federal Employer Identification Number
Business Address
Telephone Number
City
 State
Zip Code
Employer’s Signature
Employee’s Quarterly Compensation (not required for applicants checking Box b or c above)
$
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Instructions for REV-419
Employee’s Nonwithholding Application Certificate
REV-419 (IN) (EX) 03-24

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,

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 c 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.



www.revenue.pa.gov

REV-419     1