1. Single
2. Married filing jointly
3. Married filing separately
4. Head of household
5. Qualifying widow(er)
7.
Tax due - If line 3 is LESS than line 2, subtract line 3 from line 2.
If less than $5.00, enter 0
b. Federal taxable income from Form 1040 or 1040-SR, line 15. If zero, enter 0
A. Filing status used on federal return: (Fill in only one)
3. No
rth Dakota income tax withheld from wa
g
es and other
p
a
y
ments.
(
Attach Form W-2,
Form 1099, and North Dakota Schedule K-1
)
9. Balance due. Add lines 7 and 8. Pay to: ND State Tax Commissioner
with de
p
endent child
4. Over
p
a
y
ment - If line 3 is MORE than line 2, subtract line 2 from line 3; otherwise,
g
o to line 7. If less than $5.00, enter 0
(ND) 1b
(SF) 3
(SZ) 7
9
2. Tax - Enter tax on amount on line 1b from Tax Table in instructions
(SB) 2
(SG) 4
5
Enter
total
6.
Refund. Subtract line 5 from line 4. If less than $5.00, enter 0
To direct deposit
refund, complete items
a, b, and c. (See instructions)
(SR) 6
8
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.
C. Income Source Code:
(See instructions)
Tax Paid
Refund
Tax Due
Mail to: Office of State Tax Commissioner,
PO Box 5621, Bismarck, ND 58506-5621
B. School District Code:
(See instructions)
For Full-Year Residents With No Adjustments Or Credits
For a com
p
lete return,
y
ou must attach a co
py
of
y
our
entire 2021 federal income tax return
D. Fill in if you obtained
an extension to file:
See instructions
Extension
1099-G consent-I a
g
ree to obtain Form 1099-G electronicall
y
at www.nd.
g
ov/tax.
Disclosure authorization-I authorize the ND Office of State Tax Commissioner to
discuss this return with the
p
aid
p
re
p
arer identified below.
Fill in the circles that a
pp
l
y
:
(See page 10 of instructions)
Tax Calculation
1. a. Federal ad
j
usted
g
ross income from Form 1040 or 1040-SR, line 11. If zero, enter 0
(SX) 1a
5. Voluntar
y
contribution
(
s
)
: Veterans' Postwar Trust Fund
(AS)
8. Voluntary contribution(s): Veterans' Postwar Trust Fund
(AT)
Enter
total
Trees For ND Trust Fund
(SW)
(SP)
Watchable Wildlife Fund
(SU)
Watchable Wildlife Fund
(SY)
Trees For ND Trust Fund
c. Account Number
b. Routing Number
Checking Savings
a. Type Of Account
Name (First, MI, Last Name)
If Joint Return, Spouse's Name (First, MI, Last Name)
Current Mailing Address
City
State ZIP Code
Deceased
Your Social Security Number
Spouse's Social Security Number
Apt. Number
Date Of Death
Deceased
Date Of Death
Form ND-EZ
2021
INDIVIDUAL INCOME TAX RETURN
OFFICE OF STATE TAX COMMISSIONER
SFN 28745 (12-2021)
IIT
This Space Is For Tax Department Use Only
Your Signature
Date
Telephone Number
Spouse's Signature
Paid Pre
p
arer Si
g
nature
Preparer Tax ID Number
Date
Telephone Number
Print Name Of Paid Preparer Signature
Date
Telephone Number
Mail
p
a
y
ment and voucher to: Office of State Tax Commissioner
PO Box 5621
Bismarck, ND 58506-5621
ND-1PRV
City, State, ZIP Code
Mailing Address
Name
Social Securit
y
Number . . . . . . . . . . . . .
Spouse's Name
Do not use this voucher if
p
a
y
in
g
electronicall
y
2021
S
p
ouse's Social
Security Number . . . . .
FORM ND-1PRV INDIVIDUAL PAPER RETURN PAYMENT VOUCHER
North Dakota Office of State Tax Commissioner
SFN 28756
(
12-2021
)
Payment Amount
$
Write last four di
g
its of
social securit
y
number and
"2021 ND-1PRV" on check
Make
p
a
y
able to:
ND State Tax Commissioner
What is Form ND-1PRV?
The 2021 Form ND-1PRV is a payment voucher that you
complete and send in with your return if you:
arelingyour2021FormND-EZorFormND-1on
paper,
have a balance due on your return, and
arepayingthebalanceduewithapapercheckormoney
order.
Do not use Form ND-1PRV if you led or are going
to le your return electronically, or are paying
a balance due electronically - see “Electronic
payment option.”
Also do not use this form to make an extension
payment; instead, if you have an extension of time
to le your Form ND-1 and you want to make an
advance payment of an expected balance due on it,
use Form ND-1EXT.
When is the payment due?
Abalancedueona2021FormND-EZor2021
Form ND-1 must be paid on or before April 15, 2022, to
avoidanylatepaymentpenaltyandinterestcharges.
How to make payment
Makeyourcheckormoneyorderpayableto“NDState
TaxCommissioner.”Writethelastfourdigitsofyour
socialsecuritynumberand“2021ND-1PRV”onyour
checkormoneyorder.Completethepaymentvoucher,
detachitfromthispage,andmailitwithyourpayment
and return to:
OceofStateTaxCommissioner
PO Box 5621
Bismarck,ND58506-5621
OnlyacheckdrawnonaU.S.orCanadianbankinU.S.
dollarsandusingastandard9-digitroutingnumberis
accepted.
Electronic payment option. Insteadofpayingbycheck
or money order with this payment voucher, the payment
maybemadeonlinewithanelectroniccheckoradebit
orcreditcard.Theelectroniccheckoptionisfree.North
Dakotacontractswithanationalpaymentserviceto
provide the debit or credit card option, for which there is
afee,noneofwhichgoestotheStateofNorthDakota.If
paying electronically, do not use this voucher. Tomakean
electronicpayment,gotowww.nd.gov/tax/payment.
Need help?
Phone: 701-328-1242
Speechorhearingimpaired-800-366-6888
Email: individualtax@nd.gov
Privacy Act Notication. In compliance with the Privacy Act of 1974,
disclosure of a social security number or Federal Employer Identication
Number (FEIN) on this form is required under N.D.C.C. §§ 57-01-15
and 57-38-31, and will be used for tax reporting, identication, 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.
Detach here and mail with payment
INDIVIDUAL PAPER RETURN PAYMENT VOUCHER
OFFICE OF STATE TAX COMMISSIONER
SFN 28756 (12-2021)
Form ND-1PRV
2021