Montana Form Nr-1 - North Dakota Reciprocal Affidavit
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1
2MONTANA
NR-1
Rev. 08-09
North Dakota Reciprocal Affi davit
Instructions on back
Last Name (if joint affi davit, use fi rst names and
First Name and Middle Initial
Social Security Number
middle initials of both)
Spouse’s Last Name
Spouse’s First Name and Middle Initial
Spouse’s Social Security Number
Address
City
State
Zip Code
1. Enter the taxable year for which this affi davit 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 affi davit is being submitted?
yes ___
no ____
7. Are you fi ling 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 fi ling a joint affi davit, both must sign)
When you fi le 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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