Form                      North Dakota Office of State Tax Commissioner
                               Reciprocity exemption from withholding for qualifying Minnesota and
     NDW-R                     Montana residents working in North Dakota
 
     Please type or print in black or blue ink. Fill in circles completely.
 
     See instructions on back before completing
                                                                                                               For calendar year:     20

Employee information

Employee's name (last, first, middle initial)                                                              Employee's social security number

Employee's permanent address                                                                 State (fill in
                                                                                             applicable circle)
                                                                                             Minnesota
                                                                                             Montana
City                                                                                                           Zip code

 Employee residency information

 1. I have lived at the above address since (month/day/year):
                                                                          Month/Day/Year

 2. Will you return to the above address at least once a month? Yes   No           If you are a resident of Minnesota and answer "No" to this
                                                                                   question, you do not qualify for this exemption.

 3. Were you ever a resident of North Dakota in the past three years? Yes          No

     If yes, fill in the dates you were a North
     Dakota resident (month/day/year):                                               to
                                               Month/Day/Year                                              Month/Day/Year

 4. Fill in the wages you earned in North Dakota during the previous calendar year:

Employer information

Current employer's name                                                                                        Employer's federal ID

Employer's mailing address                                                                                     Phone number

City                                                                                         State             Zip code

 Employee's signature
 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.

 Employee's signature                                                 Date signed                              Employee's daytime phone number

 Employee - Make a copy for your records.  Give this completed form to your employer.
 Employer - Verify that the Employer's Federal ID is correct.  Make  a copy for your records.
                       Mail this form to:  Office of State Tax Commissioner, 600 E Boulevard Ave., Dept. 127, Bismarck, ND 58505-0599.
                                               www.nd.gov/tax

Form NDW-R instructions

Instructions for                            Fill out the form completely               Instructions for 
employee                                    If you do not fi ll in every item on this   employer
                                            form, your employer must withhold 
North Dakota has income tax reciprocity     North Dakota income tax from your          Employees who reside in Minnesota or 
agreements with Minnesota and Montana.      wages. Sign and date the form. Your        Montana who ask you not to withhold 
If you are a resident of one of these       phone number is not required, but we ask   North Dakota income tax from their 
states, the agreements provide that         for it so we can contact you if we have    wages must complete this form and give 
you do not have to pay North Dakota         questions.                                 it to you by February 28 or within 30 
income tax on wages you earn for work                                                  days after they begin working for you 
in North Dakota. If you are a resident      Your employer will be able to provide      or change their residence. Employees 
of Minnesota, this applies only if you      you with the correct federal ID number if  who live in other states, including North 
return to your permanent residence in       you do not have this information.          Dakota, cannot use this form.
Minnesota at least once a month.
Note: The wages you earn for work in        Make a copy of this form for your records  For forms received by February 28, mail 
North Dakota are subject to income tax      and give the original to your employer.    the original on or before March 31 to:
in your state of residence.                                                            Offi ce of State Tax Commissioner
                                                                                       600 E. Boulevard Ave., Dept. 127
If you do not want North Dakota             Use of information                         Bismarck, ND 58505-0599
income tax withheld from your wages,        All information on this form is 
you must complete this form and give        confi dential by state law. It may only     For new employees or employees who 
it to your employer by February 28 of       be given to your state of residence, the   change their permanent home address, 
the calendar year for which you want        Internal Revenue Service, other states     mail the original to the above address 
it to apply, or within 30 days after you    that guarantee the same confi dentiality,   within 30 days of receipt.
begin working or change your permanent      and to other state agencies as provided by 
residence. You must complete a new          law. The information may be compared       Please verify your federal ID number is 
form and give it to your employer each      with other information you furnished to    correct.  Make a copy of the completed 
year to continue the exemption from         the Offi ce of State Tax Commissioner.      form for your records.
withholding.
                                            Your name, address and social security     If an employee does not fi ll in every item 
If you do not complete this form and give   number are required for identifi cation.    on this form and the employee does not 
it to your employer as explained above,     Your address is also required to verify    correct the omission, you must withhold 
your employer must withhold North           your state of residence. Your employer’s   North Dakota income tax from the 
Dakota income tax from your wages.          name, address, federal ID number and       employee’s wages.
                                            phone number are required in case we 
If North Dakota income tax was              have to contact your employer regarding    An employee must complete this form 
already withheld from your wages, you       withholding income tax from your           and give it to you each year to continue 
must complete and fi le a North Dakota       wages. If you do not complete any of this  the exemption from withholding.
income tax return at the end of the year to information, your employer is required to 
obtain a refund.                            withhold North Dakota income tax from 
                                            your wages.

Need forms or assistance?
Visit our Web site
  You can download tax forms, ask us a question or send us a message via e-mail, and fi nd other useful information on our Web site 
at: www.nd.gov/tax.

Call us
  For additional NDW-R forms, you may call (701) 328-1243.  
  For questions about this form or about income tax withholding, please call (701) 328-1248.  
  The speech or hearing impaired may call us through Relay North Dakota at 1-800-366-6888.

Write to us
  You may also write to: Offi ce of State Tax Commissioner, 600 E. Boulevard Ave., Dept. 127, Bismarck, ND 58505-0599.