(AB) 16 (S5) 9 1. Single 2. Married filing jointly 3. Married filing separately 4. Head of household 5. Qualifying widow(er) 6. Interest from U.S. obligations b. Federal taxable income from Form 1040 or 1040-SR, line 15. If zero, see instructions A. Filing status used on federal return: (Fill in only one) B. School district code: (See instructions) C. Income source code: (See instructions) 1. a. Federal adjusted gross income from Form 1040 or 1040-SR, line 11. If zero, enter zero 2. Lump-sum distribution from Federal Form 4972 3. Loss from S corporation taxed as C corporation 7. Net long-term capital gain exclusion (From worksheet in instructions) 8. Exempt income of an eligible Native American 9. Benefits received from U.S. Railroad Retirement Board 10. Income from S corporation taxed as C corporation 16. Total other subtractions (Attach Schedule ND-1SA) 18. North Dakota taxable income. Subtract line 17 from line 5b. If less than zero, enter 0 Additions Subtractions Name (First, MI, Last Name) If Joint Return, Spouse's Name (First, MI, Last Name) Current Mailing Address City State ZIP Code with dependent child 11. Nonresident only: Servicemembers Civil Relief Act adjustment (Attach copy of Form W-2 showing this compensation) 12. North Dakota College SAVE account deduction 17. Total subtractions. Add lines 6 through 16 4. Planned gift or endowment tax credit adjustment to income Deceased Amended: General Amended: Federal NOL (SX) 1a Your Social Security Number Spouse's Social Security Number / / F. MN/MT Reciprocity (See instructions) (SS) 1b (NA) 2 (NB) 3 (NK) 4 (SN) 6 (S4) 8 (S6) 10 (NJ) 11 (AA) 12 (ND)18 Apt Number 17 5. a. Total additions. Add lines 2 through 4 5a (AO) 13 13. Qualified dividend exclusion If a fiscal year filer, enter fiscal year end: (See instructions)  (NC) 7 Date Of Death Attach a copy of your entire 2021 federal income tax return Attach W-2s, 1099s, and ND Sch. K-1s showing ND income tax withholding State Deceased 14. Military retirement pay exclusion (AQ) 14 (AR) 15 15. Social security benefit exclusion (See instructions) Date Of Death b. Add lines 1b and 5a 5b D. Fill in if applicable: (See instructions) INDIVIDUAL INCOME TAX RETURN OFFICE OF STATE TAX COMMISSIONER SFN 28702 (12-2021) Form ND-1 2021 Extension E. Fill in if applicable: (See instr.)

(AE) 23 (SQ) 30 (AK) (AL) 2021 Form ND-1 SFN 28702 (12-2021), Page 2 21. Credit for income tax paid to another state or local jurisdiction in that state (Attach Schedule ND-1CR) 22. Marriage penalty credit for joint filers (See worksheet in instr.) 24. Total credits. Add lines 20 through 23 25. Net tax liability. Subtract line 24 from line 19. If less than zero, enter 0 26. North Dakota income tax withheld from wages and other payments (Attach Forms W-2 and 1099, and ND Sch. K-1) 27. Estimated tax paid on 2021 Forms ND-1ES and ND-1EXT plus an overpayment, if any, applied from your 2020 return 28. Total payments. Add lines 26 and 27 29. Overpayment - If line 28 is MORE than line 25, subtract line 25 from line 28; otherwise, go to line 33. If less than $5.00, enter 0 30. Amount of line 29 that you want applied to your 2022 estimated tax 32. Refund. Subtract lines 30 and 31 from line 29. If less than $5.00, enter 0 33. Tax due - If line 28 is LESS than line 25, subtract line 28 from line 25. If less than $5.00, enter 0 36. Balance due. Add lines 33, 34, 35, and, if applicable, line 37. Pay to: ND State Tax Commissioner 37. Interest on underpaid estimated tax from Schedule ND-1UT To direct deposit your refund, complete items a, b, and c. (See instructions) Refund Tax Due Tax paid Other credits 34. Penalty Interest Enter total (SD) 21 (AC) 22 34 (SZ) 33 (SO) 37 36 (SR) 32 31. Voluntary contribution(s): Veterans' Postwar Trust Fund Enter total 31 (SG) 29 (AJ) 28 (S&) 27 (SF) 26 (SE) 25 24 23. Total other credits (Attach Schedule ND-1TC) I declare that this return is correct and complete to the best of my knowledge and belief. * Privacy Act - See inside front cover of booklet. Mail to: Office of State Tax Commissioner, PO Box 5621, Bismarck, ND 58506-5621  (AS) 35. Voluntary contribution(s): Veterans' Postwar Trust Fund Enter total 35 (AT) c. Account Number b. Routing Number Checking Savings a. Type Of Account (SB) 19 19. Tax - If full-year resident, enter tax on amount on line 18 from Tax Table in instructions. If full-year nonresident or part-year resident, enter tax from Schedule ND-1NR, line 23. All filers: If you have farm income or sold a research credit, see instructions (AU) 20 Watchable Wildlife Fund (SP) Trees For ND Trust Fund (SY) Watchable Wildlife Fund (SU) 1099-G consent-I agree to obtain Form 1099-G electronically at www.nd.gov/tax. Disclosure authorization-I authorize the ND Office of State Tax Commissioner to discuss this return with the paid preparer identified below. Fill in the circles that apply: (See page 16 of instructions) IIT This Space Is For Tax Department Use Only Your Signature Date Telephone Number Spouse's Signature Paid Preparer Signature PTIN Date Telephone Number Print Name Of Paid Preparer Signature Date Telephone Number Trees For ND Trust Fund (SW) 20. TAX RELIEF CREDIT - Full-year residents only. If single, head of household, qualifying widow(er), or married filing separately, enter $350. If married filing jointly, enter $700. (See instructions)