Maine Revenue Services Certified Visual Media Production Residency Affidavit printable pdf download

MAINE REVENUE SERVICES

CERTIFIED VISUAL MEDIA PRODUCTION

RESIDENCY AFFIDAVIT

36 MRSA § 6902(1) allows a certiﬁ ed visual media production company to receive a reimbursement equal

to 12% of certiﬁ ed production wages paid to, or for, individuals who are residents of Maine. To assist the

production company in qualifying my wage or payment, I,__________________________________, who

resides at ____________________________________________________________________ in the

town/city of_________________________________, Maine, hereby certify the following:

1. Check if applicable :

I ﬁ led as a resident* individual on my most recently ﬁ led Maine income tax return; or I was not

required to ﬁ le an income tax return for the most recently completed tax year, but I could have

ﬁ led as a resident individual if a return had been required; or I was claimed, or could have been

claimed as a dependent** on a Maine income tax return of an individual who ﬁ led as a resident

individual on the ﬁ ler’s most recently ﬁ led Maine income tax return.

2. The certiﬁ ed visual media production company for which this afﬁ davit applies:

Company’s Name:_________________________________________________________

Company’s Address: _______________________________________________________

_______________________________________________________________________

Company’s Employer Identiﬁ cation Number: ____________________________________

3. I authorize Maine Revenue Services (“MRS”) to inform the production company listed above if MRS

determines that I am not a Maine resident.

Under penalties of perjury, I declare that I have examined this form and related statements and to

the best of my knowledge and belief they are true, correct and complete.

_________________________________________________________________

_____________

Resident’s Signature

Date

_____________________________________________________________________________

Resident’s Printed Name

Resident’s Social Security Number:

Generally, a Maine resident is an individual (1) who was domiciled in Maine for the entire tax year or (2) who maintained a

permanent place of abode in Maine for the entire tax year and spent a total of more than 183 days in Maine. For a more

comprehensive description of Maine residency, see the Guidance to Residency Status document at

(select Forms, Publications and Applications, then select Income Tax Guidance Documents).

Maine relies on federal rules for determining dependency. Generally, an individual must pay more than 50% of your support to

claim you as a dependent for individual income tax purposes. Other rules apply. For more information, see federal Form 1040

instructions available at (select Form and Instruction Number, then select Instructions for Form 1040).

Note: Employer must retain a copy of this afﬁ davit on ﬁ le for at least 3 years

available for review by Maine Revenue Services upon request.

Rev. 5/10

Maine Revenue Services Certified Visual Media Production Residency Affidavit