Form Mt-R - Reciprocity Exemption From Withholding

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MONTANA
CLEAR FORM
MT-R
New 06 14
Reciprocity Exemption from Withholding
For North Dakota residents who work in Montana
Employee Information
First Name and Initial
Last Name
Social Security Number
XXXXXXXXXXXX
X
XXXXXXXXXXXXXXXXXXXX
XXX XX XXXX
-
-
Permanent Address
City
State
Zip Code
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XX
XXXXX XXXX
Mailing Address (if different than permanent address)
City
State
Zip Code
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XX
XXXXX XXXX
Employee Residency Information
Y Y Y Y
YYYY
Enter the taxable year for which this affidavit is being submitted ............................................................
1.
Was North Dakota your state of legal residence during the entire taxable year for
2.
X
X
which this affidavit is being submitted?
........................................................................................
Yes
No
X
X
Were you ever a Montana resident?
3
.............................................................................................
Yes
No
YYYY
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
4.
XXXXXXXXXXXX00
previous year ........................................................................................................................... $
___________________
Employer Information
Employer Name
Employer FEIN
Employer Phone Number
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XX XXXXXXX
XXX XXX XXXX
-
(
)
-
Employer’s Mailing Address
City
State
Zip Code
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XX
XXXXX XXXX
Employee’s Signature
I swear under penalty of false swearing that the information in this affidavit is true, correct and complete.
MMDDYYYY
XXX XXX XXXX
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*
*14BS0101*

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