Form MT21 "Declaration of Tax Status of Same-Sex Domestic Partner as a Dependent" - Montana

What Is Form MT21?

This is a legal form that was released by the Montana Department of Administration - a government authority operating within Montana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2010;
  • The latest edition provided by the Montana Department of Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MT21 by clicking the link below or browse more documents and templates provided by the Montana Department of Administration.

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Download Form MT21 "Declaration of Tax Status of Same-Sex Domestic Partner as a Dependent" - Montana

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Declaration of Tax Status of
Domestic Partner as a Dependent
I, _______________________________________, swear under the penalties of perjury
Print Participant’s Name
that __________________________________________ is my domestic partner and is my
Print Domestic Partner’s Name
dependent as defined by Internal Revenue Code Section 152.
Domestic Partner Information:
Domestic Partner Legal Name
Domestic Partner Social Security Number
Domestic Partner Date of Birth
I understand that the Montana VEBA HRA Third-party Administrator (TPA) has a legitimate need to know the federal
income tax status of my relationship. I understand that a domestic partner is considered an Internal Revenue Code (IRC)
§ 152 dependent only if each of the following requirements is met:
1. The domestic partner and I live together (share our principal abode) for a full previous taxable year, except for
temporary absences for reasons such as vacation, military service, or education. In other words, my domestic
partner and I must have lived together from January 1 through December 31 of the preceding year.
2. The domestic partner is a U.S. citizen or resident, or a resident of Canada or Mexico.
3. The domestic partner receives more than half of his or her support from me. The rules for determining support
are complicated and are more involved than just determining who is the “primary breadwinner.” The Internal
Revenue Service (IRS) includes in its Publication 17, a worksheet you may use to confirm if you provide more
than half of your domestic partner’s support.
Please Note:
Even if the above requirements are met, an individual cannot be considered an IRC § 152 dependent if the
relationship violates local law.
By signing below, you are stating that:
I understand that this information will be held confidential and will be subject to disclosure only upon my
express written authorization or if otherwise required by law. I understand that this declaration of responsibility
may have legal implications under federal and/or state law. I understand that a civil action may be brought
against me for any losses including reasonable attorney’s fees, because of false statement contained in this
Declaration of Tax Status of Domestic Partner as a Dependent. I also certify under penalty of perjury, that the
foregoing is true and correct.
I agree to notify the TPA at 1-800-VEBA-101 (832-2101) if there is any change in the circumstances attested to
in this declaration within 30 days of the change.
_________________________________
____________
Participant’s Signature
Montana VEBA HRA Acct No. or Social Security Number
Date
MT21 12/10
Declaration of Tax Status of
Domestic Partner as a Dependent
I, _______________________________________, swear under the penalties of perjury
Print Participant’s Name
that __________________________________________ is my domestic partner and is my
Print Domestic Partner’s Name
dependent as defined by Internal Revenue Code Section 152.
Domestic Partner Information:
Domestic Partner Legal Name
Domestic Partner Social Security Number
Domestic Partner Date of Birth
I understand that the Montana VEBA HRA Third-party Administrator (TPA) has a legitimate need to know the federal
income tax status of my relationship. I understand that a domestic partner is considered an Internal Revenue Code (IRC)
§ 152 dependent only if each of the following requirements is met:
1. The domestic partner and I live together (share our principal abode) for a full previous taxable year, except for
temporary absences for reasons such as vacation, military service, or education. In other words, my domestic
partner and I must have lived together from January 1 through December 31 of the preceding year.
2. The domestic partner is a U.S. citizen or resident, or a resident of Canada or Mexico.
3. The domestic partner receives more than half of his or her support from me. The rules for determining support
are complicated and are more involved than just determining who is the “primary breadwinner.” The Internal
Revenue Service (IRS) includes in its Publication 17, a worksheet you may use to confirm if you provide more
than half of your domestic partner’s support.
Please Note:
Even if the above requirements are met, an individual cannot be considered an IRC § 152 dependent if the
relationship violates local law.
By signing below, you are stating that:
I understand that this information will be held confidential and will be subject to disclosure only upon my
express written authorization or if otherwise required by law. I understand that this declaration of responsibility
may have legal implications under federal and/or state law. I understand that a civil action may be brought
against me for any losses including reasonable attorney’s fees, because of false statement contained in this
Declaration of Tax Status of Domestic Partner as a Dependent. I also certify under penalty of perjury, that the
foregoing is true and correct.
I agree to notify the TPA at 1-800-VEBA-101 (832-2101) if there is any change in the circumstances attested to
in this declaration within 30 days of the change.
_________________________________
____________
Participant’s Signature
Montana VEBA HRA Acct No. or Social Security Number
Date
MT21 12/10