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5 Form North Dakota Office of State Tax Commissioner 5
6 NDW-R Reciprocity exemption from withholding for qualifying 12080701 6
7 Minnesota and Montana residents working in North Dakota 7
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9 Employee information: 9
10 For calendar year: 9999 10
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SSN-99-9999
12 State: X Minnesota X Montana 12
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14 FIRSTXXXXXXXXXXXX M LASTXXXXXXXXXXXXXXXXXX 14
MAILING ADDRESSXXXXXXXXXXXXXXXXXXXXXXXXXXX
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ZIP99-9999
16 CITYXXXXXXXXXXXXXXXXXXXXXXXX ST 999-999-9999 16
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19 Employee residency information: 19
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1. I have lived at the above address since (month/day/year): MM/DD/YYYY
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2. Will you return to the above address at least once a month?
23 X Yes X No 23
24 (If you are a resident of Minnesota and answer "No" to this question, you do not qualify for this exemption.) 24
3. Were you ever a resident of North Dakota in the past three years?
25 X Yes X No 25
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27 MM/DD/YYYY to MM/DD/YYYY 27
If yes, fill in the dates you were a North Dakota resident
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4. Fill in the wages you earned in North Dakota during the previous calendar year: 9999999999
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35 Current employer information: 35
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99-9999999 EMPLOYER NAMEXXXXXXXXXXXXXXXXXXXXXX
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EMPLOYER ADDRESSXXXXXXXXXXXXXXXXXXXXXXXXXX
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CITYXXXXXXXXXXXXXXXXXXXXXXXX ST ZIP99-9999 999-999-9999
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44 Employee's signature: 44
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I declare under the penalties of North Dakota Century Code ยง12.1-11-02, which provides for a Class A misdemeanor for making a false statement
46 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. 46
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51 Employee's signature Date signed 51
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54 Employee - Make a copy for your records. Give this completed form to your employer. 54
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56 Employer - Verify that the Employer's Federal ID is correct. Make a copy for your records. 56
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58 Mail this form to: North Dakota Office of State Tax Commissioner 58
59 600 E Boulevard Ave., Dept. 127 59
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Bismarck, ND 58505-0599
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NACTP www.nd.gov/tax 12/2008
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