This form will provide Not Just Nurses, Inc. with the necessary information about your permanent residence. As a travel nurse, you must return this completed document to us before you start your assignment, or your paycheck will be reduced by the withholding taxes we are required to withhold for travel and housing benefits. The IRS requires that you pay taxes on travel reimbursement and housing benefits unless you maintain permanent residence status at least 50 miles apart from your temporary residence.
THE IRS CRITERIA USED TO DETERMINE WHETHER YOU ARE MAINTAINING A PERMANENT TAX RESIDENCE:
1. There must be a realistic expectation that you will return to live at your permanent
Residence.
2. You are maintaining your permanent residence and it is your permanent address.
3. You must meet one of the following two criteria:
· You have lived at your permanent residence immediately prior to your
current employment.
· You have either a family member using this residence or plan to return to
this residence for the purpose of lodging.
NAME: _____________________________________________ SSN _______ - _______ - _______
TEMPORARY ADDRESS: _____________________________________________________________
CURRENT PHONE: (________) ________ - __________
DO YOU HAVE A PERMANENT TAX RESIDENCE AS DEFINED BY THE 3 FACTORS ABOVE? _____________
IF YES, WHAT IS YOUR PERMANENT ADDRESS: _____________________________________________________
DO YOU HAVE FAMILY/SOCIAL TIES WITH YOUR COMMUNITY OF PERMANENT RESIDENCE? ________
ARE YOU REGISTERED TO VOTE IN YOUR COMMUNITY OF PERMANENT RESIDENCE? _______________
DO YOU FILE YOUR TAX RETURNS IN THE STATE OF YOUR PERMANENT RESIDENCE? _______________
IN WHAT CITY DO YOU DO YOU HAVE YOUR BANK ACCOUNT? ______________________________________
IF YOU OWN A CAR, IN WHAT STATE IS IT REGISTERED? ____________________________________________
DO YOU PLAN ON LEAVING ANY OF YOUR PERSONAL EFFECTS, FURNITURE, CLOTHING, ETC. AT YOUR PERMANENT RESIDENCE? _______________
WHEN DO YOU PLAN TO STOP TRAVELING? ________________________________________________________
DO YOU PLAN TO RETURN HOME WITHIN TWO YEARS? _____________________________________________