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INDIVIDUAL INCOME TAX RETURN
5 NORTH DAKOTA OFFICE OF STATE TAX COMMISSIONER 5
6 6
7 SFN 28745 (12-2021) FORM ND-EZ 7
8 8
9 2021 9
SSN-99-9999 SSN-99-9999
10 Deceased: Date of death: B. School district code: 99-999 10
11 PRIMARY(FIRST M LAST) (See instructions) 11
X MM/DD/ YYYY
12 12
SPOUSE (FIRST M LAST) X MM/DD/ YYYY
13 C. Income source code: 99 13
14 MAILINGADDRESS UNIT# (append unit# to address) (See instructions) 14
15 MAILINGADDRESSLINE2 15
16 CITY STATE ZIP D. Fill in if you obtained an extension of 16
17 time to file your return: (see instructions) 17
18 A. Filing status X 1. Single X 4. Head of household 18
19 used on X 2. Married filing jointly X 5. Qualifying widow(er) with Extension X 19
20 federal return: X 3. Married filing separately dependent child 20
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For a complete return, you must attach a copy of your entire 2021 federal income tax return
23 Tax Calculation 23
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25 1.a. Federal adjusted gross income from Form 1040 or Form 1040-SR, line 8b. If zero, enter 0. (SX) 1a 99999999999999 25
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27 b. Federal taxable income from Form 1040 or Form 1040-SR, line 11b. If zero, enter 0. (ND) 1b 99999999999999 27
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29 2. Tax - enter tax on amount on line 1b from Tax Table in instructions (SB) 2 99999999999999 29
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Tax Paid
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3. North Dakota income tax withheld from wages and other payments
32 (SF) 3 99999999999999 32
(Attach Form W-2, Form 1099, and North Dakota Schedule K-1)
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Refund
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4. Overpayment - If line 3 is MORE than line 2, subtract line 2 from line 3;
35 otherwise, go to line 7. If less than $5.00, enter 0 (SG) 4 99999999999999 35
36 Watchable Wildlife Fund (SP) 9999999 36
37 5. Voluntary contribution to: Trees for ND Program Trust Fund (SW) 9999999 Enter 5 99999999999999 37
total:
38 Veterans' Postwar Trust Fund (AS) 9999999 38
39 6. Refund - Subtract line 5 from line 4. If less than $5.00, enter 0 (SR) 6 99999999999999 39
40 To direct deposit refund, a. Type of account: XXChecking Savings 40
41 complete items a, b, and c. b. Routing Number: 999999999 41
42 (see page 9) c. Account Number: XXXXXXXXXXXXXXXXX 42
43 Tax Due 43
44 7. Tax Due - If line 3 is LESS than line 2, subtract line 3 from line 2. If less than $5.00, enter 0 (SZ) 7 99999999999999 44
Watchable Wildlife Fund
45 Trees for ND Program Trust Fund (SU) 9999999 Enter 8 99999999999999 45
46 8. Voluntary contribution to: (SY) 9999999 total: 46
47 Veterans' Postwar Trust Fund (AT) 9999999 47
48 9. Balance Due - Add lines 7 and 8. Pay to: ND State Tax Commissioner 9 9999999999999948
49 49
50 1099-G consent - I agree to obtain Form 1099-G electronically at www.nd.gov/tax 50
51 Check the boxes that apply: X 51
(see instructions) X Disclosure Authorization - I authorize the ND Office of State Tax Commissioner to discuss this return
52 with the paid preparer identified below. 52
53 I declare that this return is correct and complete to the best of my knowledge and belief. Privacy Act - See inside front cover of booklet. 53
54 Your Signature Date Telephone Number This Space Is For Tax Department Use Only 54
55 (999) 999-9999 55
56 Spouse's Signature Date Telephone Number 56
57 (999) 999-9999 57
58 Paid Preparer Signature PTIN Date 58
59 59
60 Print Name of Paid Preparer Signature Telephone number 60
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(999) 999-9999
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Mail to: State Tax Commissioner
PO Box 5621, Bismarck, ND 58506-5621 NACTPIIT
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