2006 North Dakota Reciprocal Affidavit
Instructions on back
irst Name and Middle Initial
Social Security Number
(if joint affidavit, use first names and middle initials of both)
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 ____
4. Was federal income tax withheld on the income reported on line 2?
5. Enter the name and address of the employer(s) from whom you received the income reported on line 2. If you need ad-
ditional space, use the reverse side of this form.
6. Was North Dakota your state of legal residence during the entire taxable year for which this affidavit is being submitted?
7. Are you filing a North Dakota individual income tax return reporting the income entered on line 2 above?
If yes, submit a copy of the North Dakota tax return with your Montana tax return.
8. Were you ever a Montana resident?
If yes, enter the last year you were a Montana resident ____
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
(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.