Document Number (FOIA) /ESDN (CREST):
Body:
(b) (3) (b) (6) Form D-4.A Government of the District of Columbia Income Q Franchise Tax Division Washington 1, D., C., Upon request of your employer, you must file this form with him so his records may show clearly that you are not a resident of the District of Columbia. Otherwise, he must withhold D. C. income tax from your wages. EMPLOYER: Keep this certificate with your records. If you believe the em- ployee should have filed Form D-4 in lieu of Faint D4-A, the Assessor, D. C. should be so informed. :ERTIFICATE OF NON-RESIDENCE IN !E DISTRICT OF COLUMBIA (See instructions on reverse side) Print full name _ Montrell Ee Mi.ll9----------- Social Security No. Print address 2623 _West Newton Circle ____---city Irving --- Siaie - I,MOntrell:eMills_ __ My permanent residence is _ 2623_West _Newton Circle :: istreetl s Irving-- --- ---- ------ Dallas ------- (City) --- -----'that (City) (County) ------ (State) I do not have a place of abode within the District; that I have not maintained a place of abode within the District for more than seven (7) months during this calendar year; that I do not reside within the District; and that I am not domiciled within the District. I certify under the penalties provided` by law that the above statements are true, correct, APPROVED FOR RELEASE DATE: NOV 2007