Minnesota Residency Statement
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1
2Wisconsin Department of Revenue
FOR THE
STATEMENT OF MINNESOTA RESIDENCY
Post Office Box 8906
CALENDAR YEAR
Madison., WI 53708
Telephone (608) 266-2772
_________________
▲ ▲ ▲ ▲
Fax (608) 267-0834
ENTER YEAR
Email
Income@dor.state.wi.us
Persons who are legal residents of Minnesota may use this form to:
1.
Be exempt from the withholding of Wisconsin income taxes from wages, or
2.
Claim a refund of Wisconsin Income taxes previously withheld.
PLEASE SEE THE REVERSE SIDE FOR INFORMATION BEFORE COMPLETING THIS FORM
PART A
(To be completed by employe)
Print or type your name (last, first, middle initial)
Social security number
Permanent home address (number and street)
City or post office
State
Zip Code
PART B
(To be completed by employe)
1.
On what date did you begin living at the address entered above?.....................................................................
____/____/____
mo.
day
yr.
ٱ
2.
Were you ever a resident of Wisconsin?.......................................................................................... Yes
ٱ
……………………………………………………………………………………………………. No
3.
If you answered “yes” to question 2 above, when were you a resident of Wisconsin?.............................From
____/____/____
mo.
day
yr.
To
____/____/____
mo. day
yr.
4.
What amount of wages did you earn in Wisconsin from all employers last year?.....................................
$ ___________._____
Last year means the year prior to the year this form is for.)
(
Enter zero if None
I declare that I am a legal resident of the State of Minnesota and that the above information is correct
and complete to the best of my knowledge and belief.
Signature
Date
Daytime Telephone number
(
)
PART C
(To be completed by employer if this form is being used to exempt the employe from Wisconsin withholding)
Current Wisconsin Employer’s name
Employer’s Wisconsin identification (withholding) number
Employer’s Wisconsin mailing address
Employer’s telephone number
(
)
City or post office
State
Zip code
USE OF THIS FORM
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