*171991*
2017 Form M99, Credit for Military Service in a Combat Zone
Your First Name and Initial
Last Name
Your Social Security Number
Current Home Address
Check if: New Address
Foreign Address
Your Date of Birth
City
State
Zip Code
Check if Amended Form M99
Enter the number of months served in a combat zone during 2017. Count partial months as full months. Your home of record must have been
Minnesota during the months served to qualify for the credit.
1 Number of months in 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
2 Multiply line 1 by $120. This is the AMOUNT OF YOUR CREDIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
For Direct Deposit of the full credit, enter the following information. Otherwise, you will receive a check.
(You must use an account not associated with a foreign bank.)
Account Type
Routing Number
Account Number
Checking
Savings
Sign here: I declare that this return is correct and complete to the best of my knowledge and belief.
Your signature
Date
Phone
Paid preparer’s signature
Date
Phone
PTIN or VITA/TCE # (required)
I authorize the Minnesota Department of Revenue to discuss this tax return with the preparer.
You must enclose the following with this return:
Active-duty members:
• Attach a copy of your Leave and Earnings Statement for each month in qualifying status.
National Guard, Reservists, and retired or discharged active-duty members:
• Attach Form DD-214 for each period of qualifying service.
Completed forms and documentation will be accepted starting January 2018.
Mail to: Minnesota Revenue, Mail Station 0043, St. Paul, MN 55146-0043
See instructions for additional information.
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