Form In-Compa - Indiana Composite Filing Opt-Out Affidavit - Indiana Department Of Revenue - 2014

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Indiana Composite Filing Opt-Out Affidavit
Form
IN-COMPA
State Form 52826
(R1 / 10-14)
Pass-Through Entity Information
Name of Entity
FID
Address
City, State, ZIP Code
Type of Pass-Through Entity
□
□
Partnership
S Corporation
Nonresident Member Information
Name of Member
Social Security Number
Address
City, State, ZIP Code
Declaration of Intent to Opt Out of Composite Return
Under penalties of perjury, I, _________________________ , as a nonresident member of the above-named pass-
through entity, request to be exempt from Indiana’s composite return for tax year ________________ .
I agree to timely file appropriate income tax returns and make payment of all Indiana taxes as required by law. If I fail to
abide by the terms of this affidavit, I understand that the Indiana Department of Revenue may create a pro forma resident
individual return on my behalf.
______________________________________
__________________
Signature of Nonresident Member
Date
______________________________________
_________________________
Email Address
Daytime Telephone Number
*24100000000*
24100000000

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