MWR
Reciprocity Exemption/Affidavit of Residency for Tax Year 2018
For Michigan and North Dakota residents who work in Minnesota
Read instructions on back. Please print.
Employees: Complete this form and give it to your employer.
Employee’s last name
First name and initial
Employee’s Social Security number
Permanent address
City
State (check one)
Zip code
Michigan
North Dakota
1 If you earned wages in Minnesota during the previous year, enter the wages you earned. $
(nearest dollar)
2 I have lived at the above residence since (month and year)
.
3 Do you return to the above residence at least once a month? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO*
* If your answer is NO, you do not qualify for the reciprocity exemption.
4 Were you ever a resident of Minnesota? . . . . . . . . . . . . . . . . . . . . . .
YES, from
to
.
NO
(month/year)
(month/year)
Current employer’s name
Employer’s federal tax ID
Employer’s mailing address
Employer‘s phone
City
State
Zip code
I declare that the above information is correct and complete to the best of my knowledge and belief.
I understand there is a $500 penalty for making false statements.
Employee’s signature
Date
Employee’s phone
Employers:
Mail this form to Minnesota Revenue, Mail Station 6501, St. Paul, MN 55146-6501.
Keep a copy for your records.
Note: If this form is not filled out completely, you must withhold Minnesota income tax from wages earned in
Minnesota.
(Rev. 12/17)