Form Nr-1 - North Dakota Reciprocal Affidavit
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1
2MoNtANA
NR-1
Rev 04 12
North Dakota Reciprocal Affidavit
Instructions are located on the next page.
DQ - 2011 NR-1
Social Security Numbers
field
column
row
First Name and Middle Initial
Last Name
end
start
-
-
X X X X X X X X X
ssn
65
75
13
Spouse’s First Name and Middle Initial
Last Name
spouse ssn
65
75
16
-
-
taxable year
X X X X X X X X X
51
54
20
total amount
If this is a joint affidavit, use the first names and middle initials of both spouses.
62
71
24
fein/ssn1
55
63
30
fein/ssn2
1. Enter the taxable year for which this affidavit is being submitted.
55
63
32
Y Y Y Y
X X X X
fein/ssn3
55
63
34
2. Enter the total amount of income that you received for personal or professional
fein/ssn4
55
63
36
services performed in Montana that you claim is exempt from Montana tax and
yes1
67
67
39
Montana withholding. ...............................................................................................$
X
X X X
X X X X X
no1
,
,
.
75
75
39
yes2
3. Enter the amount of income and the name(s) and address(es) of the employer(s) from whom you received the income
67
67
41
reported on line 2. If you need additional space, use the reverse side of this form.
no2
75
75
41
yes3
67
67
44
Name
Address
Employer’s FEIN/SSN
Income
no3
75
75
44
X
X X X
X X X X X
yes4
67
67
46
no4
75
75
46
X
X X X
X X X X X
yes5
67
67
49
no5
75
75
49
X
X X X
X X X X X
last taxable year
42
45
51
X
X X X
X X X X X
4. Was Montana income tax withheld on the income reported on line 2?
Yes
No
X
X
5. Was federal income tax withheld on the income reported on line 2?
Yes
No
X
X
6. Was North Dakota your state of legal residence during the entire taxable year for which this
affidavit is being submitted?
Yes
No
X
X
7. Are you filing a North Dakota individual income tax return reporting the income entered on line 2?
Yes
No
X
X
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
X
X
If yes, enter the last year you were a Montana resident.
Y Y Y Y
X X X X
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.)
*12DQ0101*
*12DQ0101*
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