Form Pt-Stm - Second Tier Pass-Through Entity Owner Statement And Request For Waiver Of The Requirement To Withhold Or Pay Composite Tax
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4MONTANA
PT-STM
Rev 07 11
Second Tier Pass-Through Entity Owner Statement and
Request for Waiver of the Requirement to Withhold or Pay Composite Tax
15-30-3313, MCA
A – First Tier Pass-Through Entity Information
Name (as it appears on the fi rst tier entity’s most recent federal tax return)
Federal Employer Identifi cation Number
-
Status Code (codes are listed in the instructions)
B – Second Tier Pass-Through Entity Information
Name (as it appears on the fi rst tier entity’s most recent federal tax return)
Federal Employer Identifi cation Number
-
Status Code (codes are listed in the instructions)
C – Information about the Second Tier Pass-Through Entity’s Owners
List each of the owners of this tiered entity and provide the requested information. Include additional pages if necessary.
1. Name
SSN or FEIN
Mailing Address
State
Zip Code
Status Code (codes are listed in the instructions)
If a S, PS or DE, complete part D.
Does this tiered entity owner fi le a Montana tax return?
Yes
No
Don’t Know
If the answer is either No or Don't Know, the fi rst tier entity must either withhold tax or pay composite tax on behalf of
the second tier entity.
2. Name
SSN or FEIN
Mailing Address
State
Zip Code
Status Code (codes are listed in the instructions)
If a S, PS or DE, complete part D.
Does this tiered entity owner fi le a Montana tax return?
Yes
No
Don’t Know
If the answer is either No or Don't Know, the fi rst tier entity must either withhold tax or pay composite tax on behalf of
the second tier entity.
This statement and all accompanying attachments represents information for the tax period from _________ to _________
I, the undersigned, declare that I am authorized to make this statement on behalf of the second tier pass-through entity
and that the statement, including all accompanying attachments, is, to the best of my knowledge and belief, true, correct
and complete.
___________________________________________
_________________________
_______________________
Signature
Title
Date
*11EB0101*
*11EB0101*
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