Form Nr-1 - North Dakota Reciprocal Affidavit
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1
2MoNtANA
NR-1
CLEAR FORM
Rev 03 11
North Dakota Reciprocal Affidavit
Instructions are located on the next page.
Social Security Numbers
First Name and Middle Initial
Last Name
-
-
Spouse’s First Name and Middle Initial
Last Name
-
-
If this is a joint affidavit, use the first names and middle initials of both spouses.
Y Y Y Y
1. Enter the taxable year for which this affidavit is being submitted.
2. Enter the total amount of income that you received for personal or professional
services performed in Montana that you claim is exempt from Montana tax and
Montana withholding. ...............................................................................................$
,
,
.
3. Enter the amount of income and the name(s) and address(es) of the employer(s) from whom you received the income
reported on line 2. If you need additional space, use the reverse side of this form.
Name
Address
Employer’s FEIN/SSN
Income
4. Was Montana income tax withheld on the income reported on line 2?
Yes
No
5. Was federal income tax withheld on the income reported on line 2?
Yes
No
6. Was North Dakota your state of legal residence during the entire taxable year for which this
affidavit is being submitted?
Yes
No
7. Are you filing a North Dakota individual income tax return reporting the income entered on line 2?
Yes
No
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
Y Y Y Y
If yes, enter the last year you were a Montana resident.
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.)
*11DQ0101*
*11DQ0101*
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