Montana Form Etm Draft - Enrolled Tribal Member Exempt Income Certification/return - 2015
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1
2MONTANA
ETM
Rev 03 15
2015 Enrolled Tribal Member
Exempt Income Certification/Return
First Name and Initial
Last Name
Social Security Number
-
-
Mailing Address
City
State
Zip Code
Physical Address (not a post office box)
City
State
Dates
(at this address)
From _________________
To ____________________
Physical Address (if you moved during the year)
City
State
Dates
(at this address)
From _________________
To ____________________
Montana Tribe (of which you are an enrolled member)
Tribal Enrollment Number
1.
Did you reside on the reservation where you are an enrolled member?
Yes
No
2.
Please check the statement that is true. Check only one.
All of my income is exempt from Montana income tax; or I had both exempt and nonexempt income, but my non-exempt
income was not enough to require that I file a Montana income tax return (Form 2).
Part of my income for the year was exempt from Montana income tax, but I did have other non-exempt income that exceeds
the Montana filing threshold. I am including this form with my completed Montana Form 2.
3.
Enter your exempt income information in the table below.
Employer’s Name (or source of exempt income)
Employer Federal Employer
Income Type
Street Address, City, State and Zip
Dates
Identification Number (FEIN)
(wages, interest, etc.)
(not a PO Box)
M M D D Y Y Y Y
From
-
M M D D Y Y Y Y
To
M M D D Y Y Y Y
From
-
M M D D Y Y Y Y
To
M M D D Y Y Y Y
From
-
M M D D Y Y Y Y
To
I declare under penalty of false swearing that I am an enrolled member of the tribe identified above, that I possess the full rights
of tribal membership, that I reside on the reservation identified above and all the information on this form and included with this
form is true, correct and complete.
*15DK0101*
Your Signature is Required
Date
Daytime Telephone Number
*15DK0101*
X
Paid Preparer’s Signature
Paid Preparer’s PTIN/SSN
Firm’s FEIN
Third Party Designee
Third Party Designee’s Printed Name
Do you want to allow another person (such as a paid
preparer) to discuss this return with us?
Third Party Designee’s Phone Number
Yes
No
Important: Since our scanners do not read photocopies correctly,
please submit this form in its original, not a photocopy.
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