Affidavit of Non-Ohio Residency/Domicile for Taxable Year 2014
IT DA
Rev. 1/15
Affidavit of Non-Ohio Residency/Domicile for Taxable Year 2014
This form is for use only by individuals who are claiming
to be full-year nonresidents for Ohio income tax purposes.
Due date: June 1, 2015. See Ohio Revised Code section 5747.24.
Who must file: Please see instructions.
Filing this affi davit does not exempt you from timely filing your Ohio income tax return for 2014 and paying any tax due.
First name M.I. Last name Social Security no.
Spouse’s fi rst name
(only if joint affidavit) M.I. Last name Spouse’s Social Security no. (only if joint affidavit)
Current mailing address County
City, state, ZIP code
Under penalties of perjury, I declare all of the following to be true:
1. I was not domiciled in Ohio at any time during taxable year 2014. Name of city (or cities), state(s) (if within the U.S.) and
country (if not within the U.S.) where I was domiciled.
2. I had at least one abode (place where I lived) outside of Ohio for the entire taxable year. Name of city (or cities), state(s)
(if within the U.S.) and country (if not within the U.S.) where I was domiciled.
3. I had no more than 182 contact periods* in Ohio during the taxable year.
4. I
shall shall not be filing a year 2014 Ohio individual income tax return.
Under penalties of perjury, I declare that to the best of my knowledge and belief the statements on this affidavit are true,
correct and complete.
Signature Date
Spouse’s signature (only if joint affidavit) Date
*Ohio Revised Code section 5747.24(A)(1) states that an individual “has one contact period in this state” if the individual is away overnight from his/her
abode located outside this state and, while away overnight from that abode, spends at least some portion, however minimal, of each of two consecutive
days in this state.
Federal Privacy Act Notice
Because we require you to provide us with a Social Security number , the Federal Privacy Act of 1974 requires us to inform
you that providing us with your Social Security number is mandatory. Ohio Revised Code sections 5703.05, 5703.057 and
5747.08 authorize us to request this information. We need your Social Security number in order to administer this tax.
Please do not attach to, or enclose with, your Ohio income tax return.
Mail to: Ohio Department of Taxation, Attn: Line Item Review,
P.O. Box 182847, Columbus, OH 43218-2847
Questions? Call us toll-free at 1-800-282-1780.
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