Certified Media Production Residency Affidavit - Maine Revenue Services printable pdf download

MAINE REVENUE SERVICES

CERTIFIED MEDIA PRODUCTION

RESIDENCY AFFIDAVIT

36 MRSA § 6902(1) allows a certiﬁ ed media production company to receive a reimbursement equal

to 12% of certiﬁ ed production wages paid to employees who are residents of Maine. To assist the

production company in qualifying my wage, I,___________________________________, who resides

at ____________________________________________________________________ in the town/

city of_________________________________, Maine, hereby certify the following:

1. Check if applicable :

I ﬁ led as a resident* individual on my most recently ﬁ led Maine income tax return; or I was not

required to ﬁ le an income tax return for the most recently completed tax year, but I could have

ﬁ led as a resident individual if a return had been required; or I was claimed, or could have

been claimed as a dependent** on a Maine income tax return of an individual who ﬁ led as a

resident individual on the ﬁ ler’s most recently ﬁ led Maine income tax return.

2. The certiﬁ ed media production company for which this afﬁ davit applies:

A. Company’s Name: ___________________________________________________

B. Company’s Address: __________________________________________________

__________________________________________________________________

C. Company’s Employer Identiﬁ cation Number: _______________________________

3. I authorize Maine Revenue Services (“MRS”) to inform the production company listed in item

2 if it is later determined by MRS that I was not a Maine resident during the certiﬁ ed media

production period.

Under penalties of perjury, I declare that I have examined this form and related statements and

to the best of my knowledge and belief they are true, correct and complete.

________________________________________________________________

______________

Resident’s Signature

Date

________________________________________________________________

Resident’s Printed Name

Resident’s Social Security Number:

Generally, a Maine resident is an individual (1) who was domiciled in Maine for the entire tax year; or (2) who maintained a permanent place of abode

in Maine for the entire tax year and spent a total of more than 183 days in Maine. For a more comprehensive description of Maine residency, see the

Guidance to Residency Status document at (select Forms, Publications and Applications, then select Income Tax Guidance

Documents).

Maine relies on federal rules for determining dependency. Generally, an individual must pay more than 50% of your support to claim you as a

dependent for individual income tax purposes. Other rules apply. For more information, see federal Form 1040 instructions available at

gov/formspubs (select Form and Instruction Number, then from the list of ﬁ les select the Instructions for Form 1040).

Note: Employer must retain a copy of this afﬁ davit on ﬁ le for at least three years available

for review by Maine Revenue Services upon request.

Rev. 06/12

Certified Media Production Residency Affidavit - Maine Revenue Services