State Tax Form

- First Name
- Last Name
- SSN*
- Home Address *
- City
- State
- Zip Code
- School district of residence
- School district no.
- Enter 0 if you are a dependent on another individual's Ohio return; otherwise enter 1*
- Enter 0 if single or if your spouse files a separate Ohio return; otherwise enter 1*
- Number of dependents*
- Total withholding exemptions (sum of line 1, 2, and 3)*
- Additional Ohio income tax withholding per pay period (optional)
- I am a full-year resident of Indiana, Kentucky, Michigan, Pennsylvania, or West VirginiaI am a resident military servicemember who is stationed outside Ohio on active duty military ordersI am a nonresident military servicemember who is stationed in Ohio due to military ordersI am a nonresident civilian spouse of a military servicemember and I am present in Ohio solely due to my spouse's military ordersI am exempt from Ohio withholding under R.C. 5747 .06(A)(1) through (6)
- Under the penalties of perjury, I certify that the number of exemptions claimed on this certificate does not exceed the number to which I am entitled.
- Signature
  
  Clear
- Date
  
  MonthDayYear
  Date
- Should be Empty: