W-2 Withholding Declaration-Montana Revenue Department Form
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1MONTANA
Clear Form
2101
Rev. 07-08
W-2 Withholding Declaration
Please print or type.
Taxpayer Name (employee) _________________________________________________________
Social Security Number _____________________________________________________________
Mailing Address
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Employer Name ___________________________________________________________________
Business Name ___________________________________________________________________
Mailing Address
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Type of Business __________________________________________________________________
Federal Employer Identifi cation Number (FEIN) __________________________________________
Tax Year _____________
Total Wages Paid ................................................................................................... $ _______________
Federal Income Tax Withheld (attach supporting documentation) ....................... $ _______________
Montana Income Tax Withheld (attach supporting documentation) ...................... $ _______________
I hereby declare under penalty of perjury that the above named employer,
(check one)
did not furnish
refused to furnish
Federal Form W-2 showing the Montana income tax withheld from my wages. The amount stated
above as Montana income tax withheld was calculated as described in the documents I have
attached to this form.
________________________________________________________
____________________
Signature of taxpayer (required)
Date
Questions? Please call us toll free at (866) 859-2254 (in Helena, 444-6900).
When you fi le your Montana income tax return electronically, you represent that you have retained all documents
required as a tax record and that you will provide a copy to the department upon request.
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