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FORM K-4 KENTUCKY S WITHHOLDING CERTIFICATE Commonwealth of Kentucky Department of Revenue Social Security Number Name Last First Middle Initial Mailing Address Number and Street including Apartment Number or P. O. Box City Town or Post Office State ZIP Code All Kentucky wage earners are taxed at a flat 5 rate with a standard deduction allowance of 2 590. The Department of Revenue annually adjust the standard deduction in accordance with KRS 141. 081 2 a. Check if exempt 1. Kentucky income tax liability is not expected this year see instructions 2. You qualify for the Fort Campbell Exemption Certificate. I am a resident of 4. You work in Kentucky and reside in a reciprocal state Additional withholding per pay period under agreement with employer Under penalties of perjury I declare that I have examined this certificate and to the best of my knowledge and belief it is true correct and complete. Signature Date Instructions to Employees You may be exempt from withholding if any of the four conditions below are met For 2018 you had a right to a refund of all Kentucky income tax withheld because you had no Kentucky income tax liability and For 2019 you expect a refund of all your Kentucky income tax withheld. If both the above statements apply you are exempt check box 1. Your exemption for 2019 expires February 15 2020. Under the provisions of Public Law 105 261 pay and compensation earned at the Fort Campbell Kentucky military base is exempt from Kentucky income tax if you are not a resident of Kentucky. KRS 141. 010 17 defines resident as an individual domiciled within this state or an individual who is not domiciled in this state but maintains a place of abode in this state and spends in the aggregate more than one hundred eighty-three 183 days of the taxable year in this state. Check box 2 if you certify that you are not a resident of Kentucky and only earn wages as an employee at Fort Campbell Kentucky. This exemption must be revoked within 10 days of a move or change of address to Kentucky. 42A804 K-4 02-2019 Relief Act as amended by the Military Spouses Residence Relief Act. You must complete the worksheet below to determine if you are eligible. In order to qualify you must complete this form in full certify that the you are not subject to Kentucky withholding tax because you met the conditions set forth below and provide a copy of your spouse s military picture ID issued to the employee by the U*S* Department of Defense. 1. My spouse is a military servicemember. check one YES 2. I am NOT a military servicemember. check one YES 3. My military servicemember spouse has a current military order assigning him or her to a military location in Kentucky. check one YES 4. I and my military servicemember spouse live at the same address. check one YES electing to use that state of domicile. check one YES If yes enter the 2-letter state code of the servicemember s state of domicile 6. I am present in Kentucky solely to be with my military servicemember spouse.

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