Maine Revenue Services Certified Media Production Residency Affidavit printable pdf download

MAINE REVENUE SERVICES

CERTIFIED MEDIA PRODUCTION

RESIDENCY AFFIDAVIT

36 M.R.S. § 6902(1) allows a certiﬁ ed media production company to receive a reimbursement equal

to 12% of certiﬁ ed production wages paid to employees who are residents of Maine. To assist the

production company in qualifying my wage, 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 media production company for which this afﬁ davit applies:

A. Company’s Name: ___________________________________________________

B. Company’s Address: __________________________________________________

__________________________________________________________________

C. Company’s Employer Identiﬁ cation Number: _______________________________

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

determined by MRS that I was not a Maine resident during the certiﬁ ed media production period.

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 from the list of ﬁ les select the Instructions for Form

1040).

Note: The media production company must retain a copy of this afﬁ davit on ﬁ le for at least three

years available for review by Maine Revenue Services upon request.

Rev. 06/14

Maine Revenue Services Certified Media Production Residency Affidavit