*221461*
Form MWR, Reciprocity Exemption/Affidavit of Residency  

for Tax Year 2022
For Michigan and North Dakota residents who work in Minnesota.

Read instructions on back.  
Employees:  Complete this form and give it to your employer.
Employee’s Last Name                                          First Name and Initial                                                                                             Employee’s Social Security Number

Permanent Address

City                                                          State  (check one)                                                                                                 ZIP Code
                                                                   Michigan            North Dakota

  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        (month/year)               to (month/year)

 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 exemption.

 4  Were you ever a resident of Minnesota?          Yes, from                           to                                                                                        No 
                                                                 (month/year)                      (month/year)

Current Employer’s Name                                                                                                                                                          Employer’s Federal Tax ID

Employer’s Mailing Address                                                                                                                                                       Employer‘s Phone Number

City                                                                 State                                                                                                       ZIP Code

I declare that the above information is correct and complete to the best of my knowledge and belief.  
I understand there is a $500 penalty for making false statements.
Employee’s Signature                                                 Date                                                                                                        Employee’s Phone Number

Employers:  Mail this form to:
            Minnesota Department of Revenue 
            Mail Station 6501 
            600 N. Robert St.
            St. Paul, MN 55146-6501   
 
            Keep a copy for your records.
            Note: If this form is not filled out completely, you must withhold Minnesota income tax from wages earned in  
            Minnesota.

(Rev. 1/22)

Form MWR Instructions

Instructions 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, fill out this form and give it to each Minnesota employer if all of these 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:
•  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 Certifi-
cate, to claim exempt from Minnesota Withholding Tax.  
Fill Out the Form Completely
If you do not complete every item on this form or do not give the form to your employer by the due date, your employer must withhold Min-
nesota income tax from your wages. 
To Get a Refund of Tax Already Withheld for the Year
File Form M1, Individual Income Tax, with the Minnesota Department of Revenue. See the Form M1 instructions for details. 
Penalties
If you make any statements on this form that you know are incorrect, we may assess a $500 penalty.
Use of Information
All information on Form MWR is private by state law. It may only be given to your state of residence, the IRS, 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 identification. Your address is also required to verify your state of resi-
dence. Your employer’s name, Federal Employer Identification Number, and address and phone number are required. 
The only information not required is your phone number. We ask for it so we can contact you if we have questions.

Instructions for Employers
Employees must provide you a complete Form MWR if one of these applies:
•  They reside in Michigan or North Dakota
• They requested that you do not withhold Minnesota income tax from their wages
Form MWR is due by February 28 each year, 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 complete every item of Form MWR or does not provide the form to you by the due date, you must withhold Min-
nesota 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 they did not complete Form W-4MN).
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 five 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 do not send us when required.

Forms and Information
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.