District of Columbia Form D-4A
Certificate of Nonresidence in the District of Columbia
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Government of the
District of Columbia
First name
2010
Form D-4A Certificate of Nonresidence in the District of Columbia
Enter Year
M.I. Last name
Temporary DC address (number and street)
Social security number
Permanent address (number and street)
City
State
Apartment number
Zip code + 4
Country or U.S. commonwealth
Signature
Signature
Under penalties of law, I certify that my permanent residence is not in DC and that I will not be residing in DC for 183 days or more in the tax year.
Date
01/18/2010
Revised 08/09
Instructions
Who must file a Form D-4A?
If you are not a resident of DC you must file a Form D-4A
with your employer to establish that you are not subject to DC
income tax withholding. You qualify as a nonresident if:
• Your permanent residence is outside DC during all of
the tax year and you do not reside in DC for 183 days or
more in the tax year.
• You are a service member’s spouse.
Employees who are residents of DC should file a Form D-4,
Employee Withholding Allowance Certificate.
What if your resident status changes?
If you become a DC resident any time after you have filed
a Form D-4A with your employer, you must file a Form D-4
promptly so that the proper amount of DC income tax can be
withheld from your wages.
How do you file the Form D-4?
After completing this form, give it to your employer to keep
on file.