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5 Form North Dakota Office of State Tax Commissioner 5
6 NDW-M  Exemption from withholding for a qualifying 06144001 6
7 7
spouse of a U.S. armed forces servicemember
8 For Calendar Year: XXXX 8
9 9
10  10
11 Employee - See "Instructions for employee" for eligibility requirements and other information. 11
 
12 Employer - See "Instructions for employer" for the purpose and proper handling of this form. 12
13 13
14 Part 1 - To be completed by the employee 14
15 1. For each of the following statements, indicate whether it is true or false by filling in the appropriate checkbox.  If any 15
16 of the statements are false, you are not eligible for the withholding exemption. 16
17 17
18 TRUE FALSE 18
19 X X 19
a. I am not a member of the U.S. armed forces
20 X X 20
b. I am married to an active duty member of the U.S. armed forces
21 X X 21
c. My military spouse and I are domiciled in a state other than North Dakota
22 X X 22
d. My military spouse's permanent duty station is in North Dakota
23 23
e. I am residing and working in North Dakota only because I want to be with
24 X X 24
my military spouse while he or she is stationed in North Dakota.
25 25
26 2. If ALL of the statements in Part 1 are true, provide the following information for you (the employee) and your military 26
27 spouse.  All boxes must be filled in to be valid. 27
Name (First, MI, Last) Social Security Number State of domicile (legal residence)
28 Employee 28
29 Information XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX-XX-XXXXXXXXXXXXXXXXXXXX 29
30 Street address where currently residing City State Zip Code 30
31 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXX-XXXX 31
32 Military Name (First, MI, Last) Social Security Number 32
33 Spouse XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX-XX-XXXX 33
34 Information Military spouse's permanent duty station Military spouse's state of domicile (legal residence) 34
35 35
36 36
37 3. I declare, under penalty of perjury, that the wages I earn for my military services performed in North Dakota are 37
38 exempt from North Dakota income tax because I meet the conditions of the Military Spouses Residency Relief Act (P.L. 38
39 111-97), and the information I provided on this form is accurate to the best of my knowledge and belief. 39
40 Employee's signature Date signed Phone number 40
41 41
XXX-XX-XXXX
42 42
 
43 ATTACH A COPY OF YOUR DEPENDENT MILITARY ID CARD ISSUED BY THE U.S. DEPARTMENT OF DEFENSE 43
 
44 Give the completed Form NDW-M with the attached copy of military ID card to your employer 44
 
45 Notify your employer if you become ineligible for this exemption - see instructions 45
 
46 You must complete a new Form NDW-M each year to maintain the exemption - see instructions 46
47 47
48 Part 2 - To be completed by the employer 48
49 49
50 Note: An employer shall be held harmless from liability for withholding based on the employee's representations on this form. 50
51 Employer name Employer identification number (EIN) 51
52 52
53 Address City State Zip Code 53
54 54
55  55
56 See "Instructions for employer" for the proper handling of this form. 56
57 57
Privacy Act Information.  In compliance with the Privacy Act of 1974, the disclosure of a social security number or a
58 58
59 federal employer identification number (EIN) on this form is required under N.D.C.C.57-01-15 and 57-38-56, and will be 59
60 used for tax reporting, identification, and administration of North Dakota tax laws.  Disclosure is mandatory.  Failure to 60
61 provide the social security number or FEIN may delay or prevent the processing of this form. 61
62 62
NACTP www.nd.gov/tax 6/2014
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Form North Dakota Office of State Tax Commissioner
NDW-M Exemption from withholding for a qualifying
spouse of a U.S. armed forces servicemember
For Calendar Year:

Employee - See "Instructions for employee" for eligibility requirements and other information.

Employer - See "Instructions for employer" for the purpose and proper handling of this form.

Part 1 - To be completed by the employee
1. For each of the following statements, indicate whether it is true or false by filling in the appropriate checkbox. If any
of the statements are false, you are not eligible for the withholding exemption.

TRUE FALSE
a. I am not a member of the U.S. armed forces
b. I am married to an active duty member of the U.S. armed forces
c. My military spouse and I are domiciled in a state other than North Dakota
d. My military spouse's permanent duty station is in North Dakota
e. I am residing and working in North Dakota only because I want to be with
my military spouse while he or she is stationed in North Dakota.
2. If ALL of the statements in Part 1 are true, provide the following information for you (the employee) and your military
spouse. All boxes must be filled in to be valid.
Name (First, MI, Last) Social Secur ty Number State of domicile (legal residence)
Employee
Information
Street address where currently residing C ty State Zip Code

Military Name (First, MI, Last) Social Security Number
Spouse
Information Mil tary spouse's permanent duty stat on Military spouse's state of domicile (legal residence)

3. I declare, under penalty of perjury, that the wages I earn for my military services performed in North Dakota are
exempt from North Dakota income tax because I meet the conditions of the Military Spouses Residency Relief Act (P.L.
111-97), and the information I provided on this form is accurate to the best of my knowledge and belief.
Employee's signature Date signed Phone number

ATTACH A COPY OF YOUR DEPENDENT MILITARY ID CARD ISSUED BY THE U.S. DEPARTMENT OF DEFENSE

Give the completed Form NDW-M with the attached copy of military ID card to your employer

Notify your employer if you become ineligible for this exemption - see instructions

You must complete a new Form NDW-M each year to maintain the exemption - see instructions

Part 2 - To be completed by the employer

Note: An employer shall be held harmless from liability for withholding based on the employee's representations on this form.
Employer name Employer dentificat on number (EIN)

Address C ty State Zip Code

See "Instructions for employer" for the proper handling of this form.

Privacy Act Information. In compliance with the Privacy Act of 1974, the disclosure of a social security number or a
federal employer identification number (EIN) on this form is required under N.D.C.C.57-01-15 and 57-38-56, and will be
used for tax reporting, identification, and administration of North Dakota tax laws. Disclosure is mandatory. Failure to
provide the social security number or FEIN may delay or prevent the processing of this form.

www.nd.gov/tax 6/2014

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it. Domicile is based on your intent
Instructions to and actions, which must be consistent. Instructions for
Form NDW-M The Servicemembers Civil Relief employer
Act provides that the domicile of a
U.S. armed forces servicemember
Purpose of form does not change based only on the Requirement to withhold
The Military Spouses Residency Relief servicemember’s presence in a state in North Dakota income tax law requires
Act (“Act”) (P.L. 111-97) is federal compliance with military orders. The you to withhold North Dakota income
legislation that was signed into law on Military Spouses Residency Relief Act tax from wages paid to an employee if
November 11, 2009. This Act amended provides that a civilian spouse’s domicile the employee performs services within
the Servicemembers Civil Relief Act to does not change based only on the North Dakota and the wages are subject
provide a number of beneﬁ ts to civilian civilian spouse’s presence in a state to be to federal income tax withholding.
spouses of active duty U.S. armed forces with the servicemember.
servicemembers. If certain conditions Form NDW-M exemption
are met, a civilian spouse’s compensation Completing Form NDW-M
An exception to the requirement to
received for working in the state where If you meet all of the eligibility withhold North Dakota income tax
the servicemember spouse is stationed is requirements for the exemption from applies if an employee completes and
exempted from that state’s income tax. withholding, ﬁ ll in the last two digits of gives to you a Form NDW-M. This
the calendar year in the upper right-hand exception applies only if you have a
A civilian spouse (employee) whose corner, then ﬁ ll out Items 1 through 3 of Form NDW-M on ﬁ le for the employee;
wages are exempt from North Dakota Part 1. Attach a copy of your dependent it is not enough that the employee is
income tax because of the Act may use military ID card to Form NDW-M, and eligible for the exemption under the Act.
Form NDW-M to apply for exemption give them to your employer.
from North Dakota income tax
withholding. What you must do
When the withholding
exemption takes effect If an employee gives you a completed
Form NDW-M, do the following:
Form NDW-M takes effect on the later of
Instructions for 1. Check to see that all items in Part 1
(1) the date you give it to your employer are ﬁ lled in and a copy of the
employee or (2) the ﬁ rst payroll period your employee’s dependent military ID
employer is able to put the exemption card is attached. If not, return the
Eligibility into effect. The exemption does not form to the employee.
apply to wages paid prior to the date 2. Fill in Part 2.
If you are a civilian spouse of an active Form NDW-M takes effect. 3. Keep the original signed
duty U.S. armed forces servicemember,
Form NDW-M and the attached
you may complete Form NDW-M if you Annual renewal copy of the military ID card for your
meet all of the following conditions:
Form NDW-M is valid only for the payroll records; it relieves you of
• You and your servicemember spouse calendar year for which it is completed. your obligation to withhold North
maintain domicile in a state other than Provided you are still eligible, you Dakota income tax, and you shall
North Dakota. This applies even if must ﬁ le a new Form NDW-M for each be held harmless from liability for
you have different states of domicile. subsequent year you want to continue withholding based on the employee’s
See “Domicile outside North Dakota” the exemption from North Dakota representations on the form.
below. withholding. 4. Mail a copy of the completed
• Your servicemember spouse’s
Form NDW-M and attached military
permanent duty station is in North
Notiﬁ cation of ineligibility ID card to:
Dakota.
• You are in North Dakota only because You must notify your employer to begin Attn: Withholding Tax Section
you want to be with your service- the withholding of North Dakota income Ofﬁ ce of State Tax Commissioner
member spouse who is stationed in tax from your wages if you become 600 E. Blvd. Ave., Dept. 127
North Dakota. ineligible for the exemption. This would Bismarck, ND 58505-0599
occur in any of the following cases: Or fax it to the Withholding Tax
Domicile outside North • Divorce from the servicemember. Section at (701) 328-1942.
Dakota • Death of the servicemember.
“Domicile” refers to your residence • Change in domicile to North Dakota
by law, and is also referred to as your by either spouse.
legal residence. It is the place that • Change in the servicemember’s Questions
is your permanent home, and is the permanent duty station to a location If you have questions about this form,
place to which you always intend to outside North Dakota. call the Withholding Tax Section at
return whenever you are absent from (701) 328-1248. Or send an e-mail to
withhold@nd.gov.

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