Montana Form Nr-1 - 2005 North Dakota Reciprocal Affidavit

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MONTANA
NR-1
Rev. 9-05
2005 North Dakota Reciprocal Affidavit
Instructions on back
F
Last Name
irst Name and Middle Initial
Social Security Number
(if joint affidavit, use first names and middle initials of both)
Address
City
State
Zip Code
Spouse’s Social Security Number
1. Enter the taxable year for which this affidavit is being submitted _________
2. Enter the amount of income that you received for personal or professional services rendered within Montana for which
you claim exemption. $_________________
3. Was Montana income tax withheld on the income reported on line 2? yes ____
no ____
4. Was federal income tax withheld on the income reported on line 2?
yes ____
no ____
5. Enter the name and address of the employer(s) from whom you received the income reported on line 2. If you need
additional space, use the reverse side of this form.
Name
Address
6. Was North Dakota your state of legal residence during the entire taxable year for which this affidavit is being submitted?
yes ___
no ____
7. Are you filing a North Dakota individual income tax return reporting the income entered on line 2 above?
yes ___
no ____
If yes, submit a copy of the North Dakota tax return with your Montana tax return.
8. Were you ever a Montana resident?
yes ___
no ____
If yes, enter the last year you were a Montana resident ____
I
swear that the above information is true and correct to the best of my knowledge and is submitted in good faith.
________________________________
____________
_________________________________
__________
Your Signature is required
Date
Spouse’s Signature
Date
(if filing a joint affidavit, both must sign)
When you file your Montana income tax return electronically, you represent that you have retained all
documents required as a tax record and that you will provide a copy to the department upon request.
129

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