Certificate of Residence Form WH-47 SF# 9686 (R/12-97) This form is to be used only by residents of States with a reciprocal tax agreement.* Indiana Employer's Name Employer TID Number Employee Name Street and City Address Social Security Number The employee swears to be a legal resident of the State of , does not own personal property in Indiana, and understands that income from salaries, wages, tips and commissions received from Indiana sources are taxable in their state of residence and not subject to Indiana Adjusted Gross Income Tax as a result of the reciprocal tax agreement with the State of . Employee further states the Indiana employer will be advised of any change in legal residence. Note: The employee understands that the employer remains responsible for withholding any applicable Indiana County taxes. Date , Employee Signature Subscribed and sworn to before me, a Notary Public in and for said County and State, this , My Commission Expires . day of Notary Public Signature My County of Residence Do not send this form to the Indiana Department of Revenue it is to be filed with and held by the employer. *States that have reciprocal agreements with Indiana are: Kentucky, Michigan, Ohio, Pennsylvania and Wisconsin. American LegalNet, Inc. www.FormsWorkflow.com