Employee’s Last Name First Name and Inial Employee’s Social Security Number
Permanent Address
City State (check one) ZIP Code
Current Employers Name Employer’s Federal Tax ID
Employer’s Mailing Address Employer‘s Phone
City State ZIP code
(Rev. 7/19)
Form MWR, Reciprocity Exempon/Adavit of Residency for Tax Year 2020
For Michigan and North Dakota residents who work in Minnesota
Michigan North Dakota
Employee’s Signature Date Employee’s Phone
I declare that the above informaon is correct and complete to the best of my knowledge and belief.
I understand there is a $500 penalty for making false statements.
Read instrucons on back.
Employees: Complete this form and give it to your employer.
Employers: Mail this form to:
Minnesota Department of Revenue
MailStaon6501
600N.RobertSt.
St.Paul,MN55146-6501
Keep a copy for your records.
Note:Ifthisformisnotlledoutcompletely,youmustwithholdMinnesotaincometaxfromwagesearnedin
Minnesota.
1 IfyouearnedwagesinMinnesotaduringthepreviousyear,enterthewagesyouearned$
(Round to the nearest dollar)
2 Howlonghaveyoulivedatyourpermanentresidence?From to
3 Doyoureturntoyourpermanentresidenceatleastonceamonth? Yes No
If your answer is no, STOP HERE. You do not qualify for the reciprocity exempon.
4 WereyoueveraresidentofMinnesota?
Yes, from to No
(month/year) (month/year)
(month/year) (month/year)
Form MWR Instrucons
Instrucons for Employees
Minnesota has income tax reciprocity agreements with Michigan and North Dakota. These agreements only cover personal service income
such as wages, bonuses, tips, and commissions.
Every year, ll out this form and give it to each Minnesota employer if all of the following apply:
You are a resident of Michigan or North Dakota
You return to your residence in that state at least once a month
You do not want Minnesota income tax withheld from your wages
Give the completed form to your employer by the later of the following:
February 28
30 days after you begin working or change your permanent residence
If you complete and submit Form MWR, you do not need to complete form W
-4MN, Minnesota Employee Withholding/Exemption Certi-
cate, to claim exemption from Minnesota withholding tax.
Fill Out the Form Completely
If you do not ll in every item on this form or do not give the form to your employer by the due date, your employer must withhold Minne-
sota income tax from your wages.
To Get a Refund of Tax Already Withheld for the Year
File Form M1, Minnesota Individual Income Tax Return, with the Minnesota Department of Revenue. See the Form M1 Instructions for
details.
Penales
If you make any statements on this form that you know are incorrect, you may be assessed a $500 penalty.
Use of Informaon
All information on Form MWR is private by state law. It may only be given to your state of residence, the Internal Revenue Service, and to
other state tax agencies as provided by law. The information may be compared with other information you gave to the Minnesota Department
of Revenue.
Your name, address and Social Security number are required for identication. Your address is also required to verify your state of residence.
Your employers name, federal tax ID number, address and phone number are required.
The only information not required is your phone number. However, we ask that you provide it so we can contact you if we have questions.
Instrucons for Employers
Employees who reside in Michigan or North Dakota who ask you not to withhold Minnesota income tax from their wages must complete this
form and give it to you each year by the later of February 28 or within 30 days after they begin working for you or change their residence.
Employees who live in other states, including Minnesota, cannot use this form.
If an employee does not ll in every item of Form MWR or does not provide the form to you by the due date, you must withhold Minnesota
income tax, using the same marital status and number of allowances claimed on the employee’s Minnesota Form
W-4MN or federal Form
W-4.
If the employee provides you with a properly completed Form MWR, the employee is not required to complete Form W
-4MN to claim ex-
emption from Minnesota income tax withholding.
Submit Completed Forms MWR to the Department
By March 31 of each year, send the completed Forms MWR to:
Minnesota Department of Revenue
Mail Station 6501
600 N. Robert St.St. Paul, MN 55146-6501
You must keep a copy of all forms for ve years from the date received.
For new employees or employees who change their state of residence, send the form within 30 days after the employee gives it to you.
You may be assessed a $50 penalty for each form you are required to send us but do not.
Forms and Informaon
Website: www.revenue.state.mn.us
Email: withholding.tax@state.mn.us
Phone: 651-282 9999 or 1-800-657-3594.
This information is available in alternate formats.