MONTANA
CLEAR FORM
FTB
Rev 04 11
2011 Montana First-time Home Buyer Savings Account
Annual Reporting Information for Self-administered Accounts
15-63-101 through 15-63-205, MCA
First Name and Initial
Last Name
Social Security Number
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Name and address of the fi nancial institution where your Montana fi rst-time home buyer savings account is established:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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Your Montana fi rst-time home buyer savings account number
Part I. Allowable exclusion calculation
1. Current year deposits (Column A if using FTB-Worksheet) ........................ 1.
2. Deposits from prior years not previously excluded ..................................... 2.
3. Add lines 1 and 2 ........................................................................................ 3.
4. Enter the lesser of the amount on line 3 or $3,000...................................................................4.
5. Interest and other income (Column B if using FTB-Worksheet) ...............................................5.
6. Add lines 4 and 5. This is your Montana First-time Home Buyer Savings Account exclusion.
Enter this amount on Form 2, Schedule II, line 19 ...................................................................6.
7. If the amount on line 3 is greater than $3,000, subtract line 4 from line 3.
These are your excess deposits that may be excluded next year. ...........................................7.
Part II. Nonqualifi ed withdrawals
1. Nonqualifi ed withdrawals (Column D if using FTB-Worksheet) ................................................1.
Enter this amount on Form 2, Schedule I, line 8.
2. Enter the withdrawals on line 1 made on the last business day in December 2011. ................2.
3. Subtract line 2 from line 1 .........................................................................................................3.
4. Multiply the amount on line 3 by 10% (0.10). Enter this amount on Form 2, line 52 and write
“FTB” in the space provided. This is your penalty ....................................................................4.
The Montana First-time Home Buyer Savings Account Worksheet (FTB-Worksheet) is available to help you reconcile the
activity on this form by providing a log to track deposits, withdrawals, fees and other transactions. It is not required to be
completed or included with your tax return. (The FTB-Worksheet follows the instructions.)
If you fi le your Montana tax return electronically, you do not need to mail this form to us unless we ask you for a copy. When you fi le electronically, you
represent that you have retained the required documents in your tax records and will provide them upon the department’s request.
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