Form Iccr - Reciprocity Exemption For Individual Construction Contractors - 2012
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2ICCR
2012 Reciprocity Exemption for Individual Construction Contractors
For individual construction contractors (payees) who are Michigan or North Dakota residents
performing work for a construction contractor (payer) in Minnesota
Note: Law Change for Individual Construction Contractors
After June 30, 2012, businesses are no longer required to withhold 2 percent from payments made to in-
dividual construction contractors. For details, go to our website at and see “Law
Change for Individual Construction Contractors” under the What’s New tab in Withholding Tax.
Read instructions on back. Please print.
Individual construction contractor (payee): Complete this form and give it to the construction contractor (payer).
Last name of individual construction contractor (payee)
First name and initial
Social Security number
Permanent home address
City
State (check one)
Zip code
Michigan
North Dakota
Business address (if different than above)
City
State
Zip code
1 I have lived at the above residence since (month and year)
.
2 Do you return to the above residence at least once a month? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO*
* If your answer is NO, you do not qualify for the reciprocity exemption.
3 Were you ever a resident of Minnesota? . . . . . . . . . . . . . . . . . .
YES, from
to
.
NO
(month/year)
(month/year)
Name of current Minnesota construction contractor (payer)
Minnesota tax ID number
Address of Minnesota construction contractor (payer)
Phone
City
State
Zip code
Minnesota
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.
Signature of independent construction contractor (payee)
Date
Daytime phone
Construction contractor (payer):
Mail this form to Minnesota Revenue, Mail Station 6501, St. Paul, MN 55146-6501.
Keep a copy for your records.
Note: If this form is not filled out completely, you must withhold 2 percent income tax from payments made for work
performed in Minnesota.
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