Form Montana Nr-1 - North Dakota Reciprocal Affidavit - 2010
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1CLEAR FORM
MoNtANA
NR-1
Rev. 11 10
North Dakota Reciprocal Affidavit
Instructions on back
Last Name
First Name and Middle Initial
Social Security Number
Spouse’s Last Name
Spouse’s First Name and Middle Initial
Spouse’s Social Security Number
Address
City
State
Zip Code
If this is a joint affidavit, use the first names and middle initials of both spouses.
1. Enter the taxable year for which this affidavit is being submitted.
2. Enter the total amount of income that you received for personal or professional services performed in Montana that you
claim is exempt from Montana tax and Montana withholding.
$ ______________
3. Enter the amount of income and the name(s) and address(es) 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
Employer’s FEIN/SSN
Income
4. Was Montana income tax withheld on the income reported on line 2?
yes ____
no ____
5. Was federal income tax withheld on the income reported on line 2?
yes ____
no ____
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?
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 under penalty of false swearing that the information in this affidavit is true.
_______________________________________ _______________ ______________________________
______________
Your Signature (required)
Date
Spouse’s Signature
Date
(If filing a joint affidavit, both must sign.)
*12200101*
1220
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