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Montana Form Mt-R Draft - Reciprocity Exemption From Withholding For North Dakota Residents Who Work In Montana - 2016

MONTANA

MT-R

Rev 07 16

Reciprocity Exemption from Withholding

For North Dakota residents who work in Montana

Employee Information

First Name and Initial

Last Name

Social Security Number

Permanent Address

City

State

Zip Code

Mailing Address (if different than permanent address)

City

State

Zip Code

Employee Residency Information

Y Y Y Y

Enter the taxable year for which this affidavit is being submitted ............................................................

Was North Dakota your state of legal residence during the entire taxable year for

which this affidavit is being submitted?

........................................................................................

Yes

Were you ever a Montana resident?

.............................................................................................

Yes

Y Y Y Y

If yes, enter the last year you were a Montana resident ..........................................................................

Enter the wages you earned in Montana from the employer listed below during the

previous year ........................................................................................................................... $

___________________

Employer Information

Employer Name

Employer FEIN

Employer Phone Number

(

)

Employer’s Mailing Address

City

State

Zip Code

Employee’s Signature

I swear under penalty of false swearing that the information in this affidavit is true, correct and complete.

M M D D Y Y Y Y

(

)

_________________________________________

Signature

Date

Daytime Phone

Employee - Please make a copy for your records. Give this completed form to your employer.

Employer - Please verify the employer information, including the FEIN, is correct. Make a copy for your records. Mail this

form to Montana Department of Revenue, PO Box 5805, Helena, MT 59604-5805.

Note: If this form is not filled out completely, you will need to withhold Montana income tax from wages

earned in Montana.

*14BS0101*

Montana Form Mt-R Draft - Reciprocity Exemption From Withholding For North Dakota Residents Who Work In Montana - 2016

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