DIVISION OF REVENUE AND TAXATION Department of Finance COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS Territorial Individual Income Tax Return

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1 I COMMOWLH O H OICIL ORHR MRI ISLDS S L DIVISIO O RVU D XIO Department of inance COMMOWLH O H ORHR MRI ISLDS erritorial Individual Income ax Return D COMMO P WLH R M O H ORHR O MR I ISLDS C orm 100-CM Your first name and initial Last name 015 or official use only Your social security number If a joint return, spouse's first name and initial Last name Spouse s social security r number Spouse s social security number Home address (number and street). If you have a P.O. box, see instructions. City, town, or post office, state and ZIP code. If you have a foreign address, see instructions. pt. o. Make sure the SS(s) above and on line 6c are correct oreign country name oreign province/state/county oreign postal code iling status Check only one box. 1 Single 3 Married filing jointly (even if only one had income) Married filing separately. nter spouse s SS above and full name here 5 Head of household (with qualifying person).(see person).(see instructions) If the qualifying person is a child but not your dependent, enter this child's name here Qualifying widow(er) with dependent child (see instructions) xemptions If more than five dependents, see instructions 6a Yourself. If your someone parent can (or claim someone you as else) a dependent, can claim do you not as check a dependent box 6aon his or her tax return, do not o. of boxes b Spouse checked on } 6a and 6b c Dependents: () If child under age o. of children ()Dependent's social (3) Dependent's 17 qualifying for child tax on 6c who: (1) irst name Last name security number relationship to you credit (see instructions) lived with you did not live with you due to divorce or separation (see instructions) Dependents on 6c not entered above Income ttach orm(s) W- and W-CM here. lso attach orm(s) 1099-R If you did not get a W- and/ or W-CM, see instructions djusted gross income d otal number of exemptions claimed... SOURC O ICOM 7 Wages, salaries, tips, etc. ttach orms W- and W-CM. 7 8a axable interest. ttach Schedule B if required. 8a b ax-exempt interest. Do not include on line 8a. 8b 9a Ordinary dividends. ttach Schedule B if required. 9a b Qualified dividends (see instructions). 9b 10 Capital gains distributions (see instructions) a IR 11b axable amount d istributions. 11a (see instructions). 11b 1a Pensions 1b axable amount and annuities 1a (see instructions). 1b 13 Unemployment compensation and laska Permanent und dividends. 13 1a Social Security 1b axable amount benefits. 1a (see instructions). 1b 15a dd amounts shown in all columns for lines 7 through 1b. his is your total income. 15a 15b llocable percentage. See instructions. 15b or Disclosure, Privacy ct, and Paperwork Reduction ct otice, see separate instructions.. ICOM WIHOU 16 ducator expenses (see instructions) IR deduction (see instructions) Student loan interest deduction (see instructions) B. ICOM WIHI % % 0 dd lines 16 through 19. hese are your total adjustments. 0 1 Subtract line 0 from line 15a, column C. his is your adjusted gross income. 1 dd numbers on lines above C. OL ICOM 100% Page 1

2 orm 100-CM (015) ax, Credits, nter the amount from line 1 (adjusted gross income) and 3a Check if: You were born before January, 1951 Blind. otal boxes Payments Spouse was born before January, 1951 Blind. } checked 3a b If you are married filing separately and your spouse itemizes deductions, check here 3b Standard deduction for nter your standard deduction 5 check any Subtract line from line. If line is more than line enter -0-5 box on line 3a or 3b or 6 6 who can be claimed as 7 axable income. Subtract line 6 from line 5. If line 6 is more than line 5, enter dependent, see 8 ax, including alternative minimum tax (see instructions) instructions. 9 xcess advance premium tax credit repayment. ttach orm Single or dd lines 8 and 9 Married filing Separately, 31 Credit for child and dependent care expenses. ttach orm 1 $6,300 3 Credit for the elderly or disabled. ttach Schedule R Married filing jointly or 33 ducation credits from orm 8863, line Qualifying widow(er) 3 Retirement savings contributions credit. ttach orm $1, Child tax credit. ttach Schedule 881, if required 35 Head of household 36 dd lines 31 through 35. hese are your total credits $9,50 37 Subtract line 36 from line 30. If line 36 if more than line 30, enter Health care: individual responsibility (see instructions). ull-year coverage dd line 37 and line 38. his is your total tax 39 0a ederal income tax withheld from orms W- and a If you have a qualifying child, attach Schedule IC Refund mount you Owe hird Party Designee Sign here Joint return? See instructions estimated tax payments and amount applied from 01 return a arned Income Credit (IC) b ontaxable combat pay election b 3 dditional child tax credit. (see supplemental instructions) merican opportunity credit. (see supplemental instructions) 5 et premium tax credit. ttach orm dd lines 0a, 0b, 1, a, and 5. hese are your total payments mount you owe. Subtract line 6 from line 39. his is the amount you owe before the non-refundable credit and rebate offset (see additional instructions on page 5, Part of the supplemental instructions 51 stimated tax penalty. ( S of the [page 3]) Do you want to allow another person to discuss this return with the Division of Revenue and axation (see instructions)? Designee's name Phone no. ( ) 0b 1 a 3 5 Personal Identification umber number (PI) 6 Yes. Complete the following. Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and accurately lists all amounts and sources of income I received during the tax year. Declaration of preparer (other than the taxpayer) is based on all information of which the preparer has any knowledge Your signature Your occupation Daytime phone number ( ) o Keep a copy for your records Spouse's signature. If a joint return, BOH must sign Spouse's occupation Paid preparer use only Print/type preparer s name irm s name irm s address Preparer's signature Check if self-employed irm s I Phone no. PI Page

3 I COMMOWLH O H OICIL ORHR MRI ISLDS (Please type or print in ink) Your first name and initial S L DIVISIO O RVU D XIO Department of inance COMMOWLH O H ORHR MRI ISLDS nnual Wage and Salary and arnings ax Return Last name 015 Your social security number D COMMO P WLH R M O H ORHR O MR I ISLDS C If a joint return, spouse s first name and initial Last name Spouse s social security number Home address (number and street). City, town or post office, state, and ZIP code. IMPOR! (See orm 100-CM supplemental instructions booklet) PR WG D SLRY X COMPUIO. You B. Spouse PR B PR C RIGS X COMPUIO CHPR COMBID X DU OR (OVRPYM) You B. Spouse. You B. Spouse If negative, enclose with parenthesis CH ORM(S) W-, W-CM, W-G D 1099 COMPL ORM OS-305 BOR COMPLIG PR D PR D CHPR 7 X D RB OS CLCULIOS If negative, enclose with parenthesis ( ) ( ) PR OL DU OR (OVRPYM) 1 otal amount due or (overpaid). dd line 6 of PR C and line 7 of PR D If line 1 is an overpayment, enter amount you want credited to your 016 estimated tax et (overpaid). dd lines 1 and of this part. his is your refund/rebate Page 3

4 PR - dditional Child ax Credit Computation Special otice his part is provided to enable the Division of Revenue and axation to process your claim of the dditional Child ax Credit (CC) Schedule 881. Please note that the CC is being paid by the United States reasury. he Division of Revenue and axation is only facilitating your CC claim as agreed upon between the CMI Department of inance and the United States reasury. By applying for the CC refund and allowing it to be processed by the Division of Revenue and axation, you are giving the Division of Revenue and axation authorization to release tax information to the Internal Revenue Service (IRS). See Supplemental Instructions for Part, line regarding rebate offset amount. 1 dditional Child ax Credit. nter the amount from line 13 of Schedule 881. (ttach Schedule 881) nter the amount due, if any, from line 1, Part, page dditional Child ax Credit refund. Subtract line from line 1, but not less than zero mount you still owe after offset of the dditional Child ax Credit. Subtract line 1 from line, but not less than zero... PR G - Refundable merican Opportunity Credit Refundable merican Opportunity Credit. nter the amount from orm 8863, line 8. (ttach orm 8863)..... nter the amount from line, Part above if applicable. Otherwise, enter amount from line 1, Part of page 3 if this amount is an underpayment Refundable merican Opportunity Credit refund. Subtract line from line 1, but not less than zero mount you still owe after offset of the ducation Credit. Subtract line 1 from line, but not less than zero hird Party Designee Sign Here Keep a copy for your records Do you want to allow another person to discuss this return with the Division of Revenue and axation? Designee's name Your signature Spouse's signature. If a joint return, BOH must sign Phone no. ( ) Your occupation Spouse's occupation Personal Identification umber (PI) Yes. Complete the following. Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Daytime phone number ( ) o Paid Preparer Use Only Print/type preparer s name irm s name irm s address signature Preparer's Check if self-employed irm s I Phone no. PI Page

5 I COMMOWLH O H OICIL ORHR MRI ISLDS S L orm OS-305 (ttach to orm 100-CM) Your first name and initial DIVISIO O RVU D XIO Department of inance COMMOWLH O H ORHR MRI ISLDS Computation of on-refundable Credit and pplication for Rebate on CMI Source Income ax (S ISRUCIOS) Last name D COMMO P WLH O H R Your social security number M ORHR O MR I ISLDS C 015 If a joint return, spouse's first name and initial Last name Spouse s social security number Home address (number and street). City, town, or post office, state and ZIP code. pt. no. IMPOR! You must enter SS(s) above PR - on-refundable Credits 1 Wage and salary tax and earnings tax... 1 PR B - Rebate Computation llocable percentage: a ax without the CMI a % b ax within the CMI b % 3 otal MI on all sources... 3 otal MI payments made... 5 ax on sources without CMI (multiply line 3 by the percentage as shown on line a) ax on sources within CMI (multiply line 3 by the percentage as shown on line b) 6 7 otal non-refundable credits (enter amount from line 1, part ) djusted CMI source tax (subtract line 7 from line 6. If zero or less, enter -0-) otal CMI and O-CMI source tax after non-refundable credits (add lines 5 and 8) MI overpayment (If line is greater than line 9, subtract line 9 from line. Otherwise, enter 0) MI underpayment (If line 9 is greater than line, subtract line from line 9. Otherwise, enter 0) 11 1 Rebate offset amount. Calculate this amount as determined by the rebate base (line 8) 1 hird Party Designee Sign Here Keep a copy for your records Do you want to allow another person to discuss this return with the Division of Revenue and axation? Designee's name Yes. Complete the following. Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Your signature Your occupation Daytime phone number Spouse's signature. If a joint return, BOH must sign Phone no. ( ) Spouse's occupation Personal Identification umber (PI) ( ) o Paid Preparer Use Only Print/type preparer s name irm s name irm s address Preparer's signature Check if self-employed irm s I Phone no. PI Deadline: pril 15, 016 Page 5

6 orm OS-305 Instructions 015 for orm 100-CM Computation of on-refundable Credit and pplication for Rebate on CMI Source Income ax PR on-refundable Credits 1. nter the wage and salary tax and earnings tax as shown on line, part C, of the nnual Wage and Salary and arnings ax Return. PR B Rebate Computation a. nter the percentage (allocable ratio) of tax without the CMI. his should be the percentage shown on line 15b, column, page 1 of orm 100-CM. b. nter the percentage (allocable ratio) of tax within the CMI. his should be the percentage shown on line 15b, column B, page 1 of orm 100-CM. 3. nter the tax as shown on line 3, page of orm 100-CM.. nter the total payments made for the taxable year as shown on line 6, page of orm 100-CM. 5. Multiply the amount on line 3 by the percentage of tax without the CMI as shown on line a. 6. Multiply the amount on line 3 by the percentage of tax within the CMI as shown on line b. 7. nter the total non-refundable credits from line 1, part. 8. Subtract line 7 from line 6. If zero or less, enter zero. 9. dd lines 5 and If line is greater than line 9, subtract line 9 from line, otherwise enter zero. 11. If line 9 is greater than line, subtract line from line 9, otherwise, enter zero. 1. Compute the amount on line 8 as shown on the rebate table below. RB BL ot over $0,000 $0,000 to $100,000 over $0,000 Page 6

7 COMMOWLH O H OICIL ORHR MRI ISLDS S L DIVISIO O RVU D XIO COMMOWLH O H ORHR MRI ISLDS Post Office Box 53 CHRB, Saipan, MP el. (670) COMM D P OWLH O H R M ORHR O MR I I ISLDS C 015 Supplemental Instructions orm 100-CM Use in Conjunction with the 015 Internal Revenue Service (IRS) orm 100 Instruction. Wage and Salary ax and arnings ax dditional Child ax Credit (Schedule 881) Refundable merican Opportunity Credit (orm 8863) Page 1

8 orm 100 CM Supplemental Instructions Lines 7 through 1b (Instruction pages 3 thru 7) he rules for the determination of source of income are established in the orthern Mariana erritorial Income ax Code ( MI") sections 861 through 865 and associated U.S. reasury regulations. axpayers and/or professionals should consult these statutes and regulations for detailed guidance on determining sources of income. You must allocate the income you are reporting on these lines between income without and within the Commonwealth based on their sources. nter your figure in the appropriate columns. Line 8a (Instruction page ) he tax on CMI sourced interest income is not subject to rebate and must be entered under column unless you elect to have this income subject to the earnings tax. You can elect to have this income subject to the earnings tax by entering the income under column B. If you enter the interest income under column B, you must include such income in the earnings tax section on page 3, Part B of the return to avoid any discrepancies on your tax return.. Line 9a (Instruction page ) he tax on CMI sourced dividend income is not subject to rebate and must be entered under column unless you elect to have this income subject to the earnings tax. You can elect to have this income subject to the earnings tax by entering the income under column B. If you enter the dividend income under column B, you must include such income in the earnings tax section on page 3, Part B of the return to avoid any discrepancies on your tax return. Line 15a otal the figures entered in each of the columns (, B, and C) from lines 7 through 1b. Line 15b Make the percentage allocation of your income on line 15a by dividing the total in each column ( and B) by the total in column C. xample: Percentage allocation for line 15b, column Line 15a, column Line 15a, column C = Percentage allocation for line 15b, column Percentage allocation for line 15b, column B Line 15a, column B Line 15a, column C = Percentage allocation for line 15b, column B Line 1 Subtract line 0 from line 15a, column C (total income). Line 0a otal ederal Income ax withheld (from orm(s) W and/or orm(s) 1099 from without CMI only). Do not include this amount on line 0b. Line 0b otal MI withheld (chapter 7 tax from orm(s) W CM and/or orm(s) 1099 from within CMI only). Do not include this amount on line 0a. Line 3 Claim the additional child tax credit (CC) in Part, page of this return. ttach Schedule 881. Page

9 Line Claim the merican pportunity redit ( OC) in Part of this return. ttach orm Line otal payments add lines a, b, &. Lines and he amount overpaid on this line is subject to adjustment that may result from allowable non-refundable credit. See instructions for Part, line 3. Line 5 he amount owed on this line is subject to adjustment that may result from allowable non-refundable credit. See instructions for Part, line 1. Line Leave this blank. See for Part D, line 6. Instruc s for orm 100-CM Wage and Salary ax, arnings ax, and Chapter 7 ax and Rebate Offset s PR Wage and Salary ax Computa n (or a joint return, enter spouse n in column B) 1. nter total wages and salaries received for work performed in the CMI per orm(s) W- and/or W-CM box 16.. nter other wages and salaries received for work performed in the CMI if W- and/or W-CM were not issued or received. i.e., and freelance income, etc. 3. dd lines 1 and under each column.. nter the amount not subject to the wage and salary tax. h otherwise this amount will be disallowed. 5. Subtract line from line 3 under each column. his is your total CMI wages and salaries subject to the wage and salary tax. 6. Compute the wage and salary tax on the amount reported on line 5 for each column using the wage and salary and earnings tax table below. X BL OR WG D SLRY D RIGS X COMPUIO rom o Rate rom o Rate (a) 0 1, (f), , % (b) 1, , % (g) 30, , % (c) 5, , % (h) 0, , % (d) 7, , % (i) 50, and over 9.0% (e) 15,000.01, % Page 3

10 PR B arnings ax Computa on (If you are filing a joint return, enter spouse n in column B) 1. nter the interest income reported on line 8a, column B, page 1 of your income tax return.. nter the dividend income reported on line 9a, column B, page 1 of your income tax return. 3. nter the amount shown on line 10, column B, page 1 of orm 100-CM.. dd lines 1,, and 3 in each column. 5. Compute your earnings tax on the amount reported on line for each column using the wage and salary and earnings tax table on page 3. PR C otal Chapter (Wage and Salary and arnings ax) Due or Overpayment 1. nter in column, the total of Part line 6, column and Part B line 5, column. lso, enter in column B the total of Part line 6, column B and Part B line 5, column B.. nter in column the amount of cash contribu ns made during the taxable year to a ed educa al in n or other tax exempt educa al on located in the CMI. If this is a joint return and your spouse made cash contr s to a ed educa onal ins tu on, enter that inform n in column B. ch Schedule C. aggregate amount of wage and salary tax, earnings tax, and business gross revenue tax liability. C shall not exceed $5, Subtract line from line 1 in each column. If line is more than line 1, enter zero. his is the Chapter tax the educa on tax credit.. nter the total amount of Columns and B, line 3. his is your combined wage and salary and earnings taxes. 5. nter the total wage and salary tax withheld and paid in 015 (Box 17 of W-CM). lso enter any earnings tax withheld and/or paid in 015. his is also known as Chapter tax. 6. Combined wage and salary and earnings tax due or overpaid. Subtract line 5 from line. If zero or less, place parenthesis around the gure to indicate an overpayment. COMPL SCHDUL OS-305 (PPLICIO OR RB O CMI SOURC X) BOR PROCDIG O PR D PR D Chapter 7 ax and Rebate Offset Calc s 1. nter amount from Schedule OS-305, line 11, Part B.. nter amount from Schedule OS-305, line 10, Part B. 3. nter amount from Schedule OS-305, line 1, Part B.. dd lines 1 through 3 of this part. ote that the amount on lines and 3 are nega ve numbers. If the amount is less than zero, place parenthesis around the gure. 5. nter the a orm 100-CM Page the amount on line Chapter 7 ax and Rebate Offset Calculations on page 3. Page

11 6. o gure your e ed tax penalty on orm 10, e the tax underpayment amount with the amount shown on line 1 of this part. If orm 10 is check the box. If you want the CMI Division of Revenue and axa on to compute this penalty for you, write RVX on the le side of this line. We will adjust your overpayment or bill you later for this amount. 7. dd lines, 5 and 6. his is your total Chapter 7 (MI) liability or overpayment. O: Line may be a nega ve number. PR Combined Due or (Overpayment) 1. mount due or (overpaid). dd line 6 of Part C and line 7 of Part D. If the amount is less than zero, enclose in If there is an amount due: (ROC) on Part G below, if any. Please complete those parts to determine your remaining tax due. Otherwise, pay this amount.. 3. nter the amount of overpayment from line 1 of this part you want amount should be less than or equal to the amount on line 1, Part above. dd lines 1 and of this part. his is your refund/rebate. he allowable 1. nter the amount from part line nter the sum of part D line 6, part line 1, and Part G line If line 1 is greater than line, subtract line from line 1.. ailure to pay penalty* 5. ailure to le penalty** 5 6. Calculate interest at prevailing rates as published by the IRS from payment, include this amount with the tax due shown on part line 1. 7 Page 5

12 PR Skip this part if you are not claiming this credit 1. nter the amount of your Child ax Credit from Schedule 881, line 13. Schedule 881 to this return.. If line 1, Part, page 3 is an underpayment, enter the amount on this line. Otherwise enter zero. If you enter the amount as requested, you are authorizing an offset of your tax due on this return against your CC. If you do not authorize an offset of your tax due, you must pay the amount shown on line 1, Part, page If line 1 is greater than line, subtract line from line 1. his is your CC refund offset.. If line is greater than line 1, subtract line 1 from line. his is the amount you s l owe CC offset. Pay this amount unless you are claiming ROC in Part G below. PR G Skip this part if you are not claiming this credit 1. nter the amount of your refundable ROC from orm 8863, line 8. ach orm 8863 to this return.. nter amount from line 1, Part, page 3 if this is an underpayment or line, Part above if applicable. Otherwise enter zero. If you enter the amount as requested, you are authorizing an offset of your tax due on this return against your ROC. If you do not authorize an offset of your tax due, you must pay the amount shown on line, Part above or the amount on line 1, Part, Page If line 1 is greater than line, subtract line from line 1. his is your ROC refund offset.. If line is greater than line 1, subtract line 1 from line. his is the amount you s l owe ROC offset. Pay this amount. Otherwise, enter zero. iling and Deadline If filing in person deliver return to any Revenue and ax on Offices: Saipan Central Office Rota District Office inian District Office Division of Revenue and axation Division of Revenue and axation Division of Revenue and axation Joeten Dandan Commercial Building San Vicente, Saipan Songsong Village, Rota San Jose Village, inian If filing by mail, send to: Saipan Central Office Rota District Office inian District Office Division of Revenue and axation Division of Revenue and axation Division of Revenue and axation P.O. Box 53 CHRB P.O. Box 106 P.O. Box 9 Saipan, MP Rota, MP inian, MP 9695 iling Deadline: pril 15, 016 Page 6