Form NDW-R Reciprocity exemption from withholding for qualifying Minnesota and Montana residents working in North Dakota

Mail this form to: Office of State Tax Commissioner 600 E Boulevard Ave Dept 127 Bismarck ND 58505 0599 1 I have lived at the above address since (month/day/year): 2 Will you return to the above address at least once a month? 4 Fill in the wages you earned in North Dakota during the previous calendar year: All information on this form is con dential by state law It may only be given to your state of residence the Internal Revenue Service other states that guarantee the same con dentiality and to other state agencies as provided by law The information may be compared with other information you furnished to the Of ce of State Tax Commissioner An employee must complete this form and give it to you each year to continue the exemption from withholding Call us City State Zip code Current employer's name Employer's federal ID Dakota resident (month/day/year): Employee information Employee Make a copy for your records Give this completed form to your employer Employee residency information Employee's name (last first middle initial) Employee's social security number Employee's permanent address Employee's signature Employee's signature Date signed Employee's daytime phone number Employees who reside in Minnesota or Montana who ask you not to withhold North Dakota income tax from their wages must complete this form and give it to you by February 28 or within 30 days after they begin working for you or change their residence Employees who live in other states including North Dakota cannot use this form Employer information Employer Verify that the Employer's Federal ID is correct Make a copy for your records Employer's mailing address Phone number Fill out the form completely For additional NDW R forms you may call (701) 328 1243 For calendar year: 20 For forms received by February 28 mail the original on or before March 31 to: Of ce of State Tax Commissioner 600 E Boulevard Ave Dept 127 Bismarck ND 58505 0599 For new employees or employees who change their permanent home address mail the original to the above address within 30 days of receipt For questions about this form or about income tax withholding please call (701) 328 1248 Form NDW R instructions Form North Dakota Office of State Tax Commissioner I declare under the penalties of North Dakota Century Code 12 1 11 02 which provides for a Class A misdemeanor for making a false statement in a governmental matter that this form has been examined by me and to the best of my knowledge and belief is true correct and complete If an employee does not ll in every item on this form and the employee does not correct the omission you must withhold North Dakota income tax from the employee s wages If North Dakota income tax was already withheld from your wages you must complete and le a North Dakota income tax return at the end of the year to obtain a refund If yes fill in the dates you were a North If you are a resident of Minnesota and answer "No" to this If you do not complete this form and give it to your employer as explained above your employer must withhold North Dakota income tax from your wages If you do not ll in every item on this form your employer must withhold North Dakota income tax from your wages Sign and date the form Your phone number is not required but we ask for it so we can contact you if we have questions If you do not want North Dakota income tax withheld from your wages you must complete this form and give it to your employer by February 28 of the calendar year for which you want it to apply or within 30 days after you begin working or change your permanent residence You must complete a new form and give it to your employer each year to continue the exemption from withholding Instructions for employee Instructions for employer Make a copy of this form for your records and give the original to your employer Minnesota Montana City Month/Day/Year Month/Day/Year Month/Day/Year Need forms or assistance? Visit our Web site No3 Were you ever a resident of North Dakota in the past three years? North Dakota has income tax reciprocity agreements with Minnesota and Montana If you are a resident of one of these states the agreements provide that you do not have to pay North Dakota income tax on wages you earn for work in North Dakota If you are a resident of Minnesota this applies only if you return to your permanent residence in Minnesota at least once a month Note: The wages you earn for work in North Dakota are subject to income tax in your state of residence Please type or print in black or blue ink Fill in circles completely Please verify your federal ID number is correct Make a copy of the completed form for your records question you do not qualify for this exemption Reciprocity exemption from withholding for qualifying Minnesota and NDW R Montana residents working in North Dakota See instructions on back before completing State (fill in applicable circle) The speech or hearing impaired may call us through Relay North Dakota at 1 800 366 6888 Use of information Write to us www nd gov/tax You can download tax forms ask us a question or send us a message via e mail and nd other useful information on our Web site at: www nd gov/tax You may also write to: Of ce of State Tax Commissioner 600 E Boulevard Ave Dept 127 Bismarck ND 58505 0599 Your employer will be able to provide you with the correct federal ID number if you do not have this information Your name address and social security number are required for identi cation Your address is also required to verify your state of residence Your employer s name address federal ID number and phone number are required in case we have to contact your employer regarding withholding income tax from your wages If you do not complete any of this information your employer is required to withhold North Dakota income tax from your wages Zip code