North Dakota Form NDW-R Reciprocity exemption from withholding for qualifying Minnesota and Montana residents working in North Dakota Click this button to begin: Begin Instructions: Move the "hand" pointer over a form box on the document. The "hand" should turn into an "I-beam". The "I-beam" signifies a "fill-in" section to the form. Click inside the box. You can now type into the box. When the pointer hovers over a check box, button, or item list, it will turn into a hand with one finger pointing. This means you can select the item. To move from field to field, use the Tab key. Shift + Tab will move you to the previous field. Fill out the form by typing text into the appropriate areas and checking boxes where needed. (Boxes can be checked either by clicking on the box with your mouse, or by tabbing into the box and hitting the "enter" key.) Print the form using the "print" button on the form itself - not the print icon or command in your web browser. If you print using your web browser's print command instead of the Acrobat button, the contents of the fields might not print properly. Check the printed forms very carefully for any errors, fields that did not print, or omissions. You may go back and make changes to any of the fields in your open document, and then reprint it. When the form is completed, click on the "Submit" button. Click this button to begin: Begin © Copyright 2003-2008, Symmetry Software, all rights reserved Patent Pending Form North Dakota Office of State Tax Commissioner NDW-R Reciprocity exemption from withholding for qualifying Minnesota and Montana residents working in North Dakota Please type or print in black or blue ink. Fill in circles completely. Print Form See instructions on back before completing For calendar year: 20 08 Employee information Employee's name (last, first, mdidle 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? 3. Were you ever a resident of North Dakota in the past three years? Yes No Yes If you are a resident of Minnesota and answer "No" to this question, you do not qualify for this exemption. 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. 10/31/2008 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.ndtaxdepartment.gov Form NDW-R instructions Instructions for employee North Dakota has income tax reciprocity agreements with Minnesota and Montana. If you are a resident of one of these states, the agreements provide that you do not have to pay North Dakota income tax on wages you earn for work in North Dakota. If you are a resident of Minnesota, this applies only if you return to your permanent residence in Minnesota at least once a month. Note: The wages you earn for work in North Dakota are subject to income tax in your state of residence. If you do not want North Dakota income tax withheld from your wages, you must complete this form and give it to your employer by February 28 of the calendar year for which you want it to apply, or within 30 days after you begin working or change your permanent residence. You must complete a new form and give it to your employer each year to continue the exemption from withholding. If you do not complete this form and give it to your employer as explained above, your employer must withhold North Dakota income tax from your wages. If North Dakota income tax was already withheld from your wages, you must complete and ﬁle a North Dakota income tax return at the end of the year to obtain a refund. Fill out the form completely If you do not ﬁll in every item on this form, your employer must withhold North Dakota income tax from your wages. Sign and date the form. Your phone number is not required, but we ask for it so we can contact you if we have questions. Your employer will be able to provide you with the correct federal ID number if you do not have this information. Make a copy of this form for your records and give the original to your employer. Use of information All information on this form is conﬁdential by state law. It may only be given to your state of residence, the Internal Revenue Service, other states that guarantee the same conﬁdentiality, and to other state agencies as provided by law. The information may be compared with other information you furnished to the Ofﬁce of State Tax Commissioner. Your name, address and social security number are required for identiﬁcation. Your address is also required to verify your state of residence. Your employer’s name, address, federal ID number and phone number are required in case we have to contact your employer regarding withholding income tax from your wages. If you do not complete any of this information, your employer is required to withhold North Dakota income tax from your wages. Instructions for employer Employees who reside in Minnesota or Montana who ask you not to withhold North Dakota income tax from their wages must complete this form and give it to you by February 28 or within 30 days after they begin working for you or change their residence. Employees who live in other states, including North Dakota, cannot use this form. For forms received by February 28, mail the original on or before March 31 to: Ofﬁce of State Tax Commissioner 600 E. Boulevard Ave., Dept. 127 Bismarck, ND 58505-0599 For new employees or employees who change their permanent home address, mail the original to the above address within 30 days of receipt. Please verify your federal ID number is correct. Make a copy of the completed form for your records. If an employee does not ﬁll in every item on this form and the employee does not correct the omission, you must withhold North Dakota income tax from the employee’s wages. An employee must complete this form and give it to you each year to continue the exemption from withholding. 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 ﬁnd other useful information on our web site at: www.ndtaxdepartment.gov. Call us Call us at (701) 328-3125. If speech or hearing impaired, call us through Relay North Dakota at 1-800-366-6888. Write to us You may also write to: Ofﬁce of State Tax Commissioner, 600 E. Boulevard Ave., Dept. 127, Bismarck, ND 58505-0599.
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