STATUTORY ADJUSTMENTS
                      OFFICE OF STATE TAX COMMISSIONER                                     Schedule ND-1SA
                      SFN 28710 (12-2022)
                                                                                                       2022
                                                                                           Attach to Form ND-1
Name  (First, MI, Last Name)                                                             Your Social Security Number

Important! All taxpayers must read this section. If you are claiming a deduction on line 1 or 2 of this schedule,
you must complete this section. See "Property tax clearance" in instructions for details.
► Do you (or does your spouse, if filing jointly) hold a 50 percent or more ownership interest in real
   property located in North Dakota?                                                                                Yes No
   If yes, enter name of each North Dakota county in which you or your spouse holds a 50% or more interest in real property:
   _________________________________________________________________________________
Attach to Form ND-1 the completed Property Tax Clearance Record obtained from each county identified above.

1. Renaissance zone income exemption (Attach Schedule RZ)                                  (S7) 1
2. New or expanding business income exemption                                              (NH) 2
3. Human organ donor expense deduction                                                     (NL) 3
4. Employee workforce recruitment exclusion                                                (CA) 4
5. a.  Stillborn child deduction                                                           (CB) 5a
   b.  11-digit certificate number from Certification
       of Fetal Death                                 (CC) 5b
   c. Date of death from Certification of Fetal Death (CD) 5c
6. National Guard/Reserve member federal active duty pay exclusion (Attach copy of
   Title 10 orders)                                                                        (NI) 6
7. Employer reimbursement of college expenses which is included in taxable wages
   on Form W-2 (Attach statement or letter from employer - see instructions)               (CE) 7
8. Total subtractions. Add lines 1 through 5a, 6 and 7. Enter result on Form ND-1, line 16            8

                                        The property tax clearance record(s) 
Instructions                            must be attached to the North Dakota               Line 2 - New or expanding 
If you have any of the adjustments      tax return on which the incentive is               business income exemption
shown on this schedule, you must        claimed. The deductions on lines 1                 If you operate a business as a sole 
complete and attach it to Form ND-1.    and 2 of this schedule are subject to              proprietorship and were granted a 
                                        this requirement.                                  new or expanding business income 
                                                                                           exemption under N.D.C.C.
Disclosure notification                 If you are claiming the deduction                  Ch. 40-57.1, enter the portion of your 
Upon written request from the           on line 1 or line 2 of this schedule,              net business income that is eligible for 
chairman of a North Dakota legislative  you must complete the property tax                 the exemption. For more information 
standing committee or Legislative       clearance section at the top of the                on how to calculate the amount of 
Management, the law requires the        schedule. If you are required to attach            the exempt income, see North Dakota 
Office of State Tax Commissioner to     a property tax clearance record from               Administrative Code
disclose the amount of any deduction    a county, obtain one by using the                  § 81-03-01.1-06. Include on this line 
or credit claimed on a tax return. Any  form Property Tax Clearance Record                 a new or expanding business income 
other confidential information, such as available on the Office of State Tax               exemption from a North Dakota 
a taxpayer’s name or social security    Commissioner’s website at                          Schedule K-1.
number, may not be disclosed.           www.tax.nd.gov.
                                                                                           Line 3 - Organ donor deduction
Property tax clearance                  Line 1 - Renaissance zone income                   If you or your dependent, while 
North Dakota Century Code (N.D.C.C.)    exemption                                          living, donates part or all of a liver, 
§ 57-01-15.1 provides that, before      If you qualified for the business                  pancreas, kidney, intestine, lung, 
certain state tax incentives may be     or investment income exemption                     or bone marrow for transplantation 
claimed, a taxpayer must obtain a       under the North Dakota renaissance                 into another human being, you may 
property tax clearance record from      zone program, enter the sum of the                 deduct up to $10,000 of qualified 
each North Dakota county in which       amounts from Schedule RZ, Part 7,                  expenses related to the donation that 
the taxpayer holds a 50% or more        line 1c. Attach Schedule RZ.                       you incurred during the tax year.
ownership interest in real property. 

2022 Schedule ND-1SA
SFN 28710 (12-2022), Page 2

Qualified expenses means:
                                         Line 5 - Stillborn child deduction       Line 7 – College expense 
   Lost wages not compensated for 
                                         You are allowed a deduction if you       reimbursement deduction 
  by sick pay.
                                         meet all of the following conditions:    If your employer paid to you, or 
   Unreimbursed medical expenses                                                 on your behalf, an amount as 
  (as defined for federal income            You are the parent of a child who    reimbursement of expenses you 
  tax purposes) that you did not           was stillborn in 2022.                 incurred for higher education or 
  deduct in calculating your federal        You received or obtained a           career and technical education, and 
  taxable income.                          certified copy of a Fetal Death        the reimbursement was included in 
The expenses are deductuble in the         Record (Certification of Fetal         the taxable wages reported in Box 1 
tax year in which they are incurred.       Death) from the North Dakota           of your Form W-2, enter the taxable 
They are incurred when the medical         Department of Health, Division         reimbursement on this line. Do not 
care is actually provided, and not         of Vital Records. This deduction       enter on this line any portion of a 
when the expenses are billed or paid.      is allowed only if a Fetal Death       reimbursement that you deducted or 
                                           Record was filed with the North        excluded from your federal taxable 
Enter on this line qualified expenses      Dakota Division of Vital Records.      income.
incurred during the tax year.               You would have been eligible to      Attach a statement or letter from 
                                           claim the child as a dependent         your employer containing the 
                                           on your 2022 federal income 
Line 4 - Employee workforce                                                       following information:
                                           tax return if the child had been 
recruitment exclusion                      born alive. For information on            A statement that the employer 
If you receive a statement from            who is entitled to a federal             paid to you, or on your behalf, 
your employer verifying that your          dependency exemption, see IRS            an amount as reimbursement for 
employer qualified for the North           Publication 501.                         higher education or career and 
Dakota workforce recruitment income                                                 technical education expenses you 
tax credit based on your employment,     If eligible, enter $4,530 on line 5a and   incurred.
enter on this line the amount of         complete lines 5b and 5c.
                                                                                     Amount of reimbursement 
the signing bonus, moving expense 
                                                                                    included in the taxable wages 
payment, or non-typical fringe benefit 
payment shown on the statement,          Line 6 - National Guard or reserve         reported in Box 1 of your 
but only to the extent it is included in member exclusion                           Form W-2. 
your federal taxable income for the      If you were a member of the North 
tax year.                                Dakota National Guard or the U.S. 
                                         armed forces reserve, and you 
Attach a copy of the statement           were mobilized or activated for 
received from your employer.             federal active duty service under 
                                         Title 10, United States Code, enter 
                                         the compensation received for that 
                                         service. Do not enter compensation 
                                         exempted from federal income 
                                         tax, nor compensation received for 
                                         attending annual training, basic 
                                         military training, or professional 
                                         military education. Attach a copy of 
                                         your Title 10 orders.