NJ 165
NJ 165
NJ 165
9-19
Street Address
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