Form 14_CertVisualMediaProdResAff.indd Fillable Media Production Residency Affidavit
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

1 Check if applicable : 1040) 2 The certified media production company for which this affi davit applies: 3 I authorize Maine Revenue Services ( MRS ) to inform the production company above if it is later 36 M R S 6902(1) allows a certified media production company to receive a reimbursement equal A Company s Name: Applications then select Income Tax Guidance Documents) at in the town/ available at www irs gov/formspubs (select Form and Instruction Number then from the list of files select the Instructions for Form B Company s Address: been claimed as a dependent** on a Maine income tax return of an individual who filed as a best of my knowledge and belief they are true correct and complete C Company s Employer Identifi cation Number: CERTIFIED MEDIA PRODUCTION city of Maine hereby certify the following: determined by MRS that I was not a Maine resident during the certified media production period filed as a resident individual if a return had been required; or I was claimed or could have Generally a Maine resident is an individual (1) who was domiciled in Maine for the entire tax year; or (2) who maintained a permanent I filed as a resident* individual on my most recently filed Maine income tax return; or I was not Maine relies on federal rules for determining dependency Generally an individual must pay more than 50% of your support to claim MAINE REVENUE SERVICES Note: The media production company must retain a copy of this affi davit on file for at least three of Maine residency see the Guidance to Residency Status document at www maine gov/revenue (select Forms Publications and place of abode in Maine for the entire tax year and spent a total of more than 183 days in Maine For a more comprehensive description production company in qualifying my wage I who resides required to fi le an income tax return for the most recently completed tax year but I could have RESIDENCY AFFIDAVIT resident individual on the filer s most recently filed Maine income tax return Resident s Printed Name Resident s Signature Resident s Social Security Number: Rev 06/14 to 12% of certified production wages paid to employees who are residents of Maine To assist the Under penalties of perjury I declare that I have examined this form and related statements and to the years available for review by Maine Revenue Services upon request you as a dependent for individual income tax purposes Other rules apply For more information see federal Form 1040 instructions