Form Der-1 - 2009 Montana Disregarded Entity Information Return

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2009 Montana Disregarded Entity Information Return

Form DER-1

For calendar year 2009 or tax year beginning (MM-DD) ___ - ___- 09 and ending (MM-DD-YY) ___ - ___ - ___

Name

Check if

FEIN or SSN:

applicable:

__________________

____Initial Return

Check this box if this

Address

If new address check here.

____Final Return

FEIN or SSN is the

same as the owner’s

____Amended

FEIN or SSN.

City

State

Zip + 4

1. Enter any assumed business name under which the entity does business in Montana __________________________

2. Enter the date the entity was incorporated or formed ____________________________________________________

3. Enter the date the entity registered with the Montana Secretary of State _____________________________________

4. Enter the state or country where the entity was incorporated or formed______________________________________

5. Disregarded Entity Type (Check appropriate entity type—See instructions for the correct box to check.)

A.  Single Member Limited Liability Company (SMLLC)

Check only one single member limited liability company owner type.

 Individual (The Montana Form DER-1 is not required to be filed if the SMLLC is owned by an individual who

has been a full-year Montana resident during the applicable reporting period.)

 S corporation

 Partnership

 Qualified Subchapter S Subsidiary

 Electing IRC § 761 Partnership

 C corporation

 Real Estate Mortgage Investment Conduit (REMIC)

 Estate

 Non-Grantor Trust

 Real Estate Investment Trust (REIT)

 Qualified REIT Subsidiary

 Any other single member not described above

B.  Entity Type Other than SMLLC

 IRC § 761 Partnership ........................................................ Enter date of election: ____________________

 IRC § 1361(b)(3) Qualified Subchapter S Subsidiary ......... Enter date of election: ____________________

 IRC § 856(i)(2) Qualified Real Estate Investment Trust Subsidiary

 IRC § 860D Real Estate Mortgage Investment Conduit (REMIC). Attach a copy of federal Form 1066.

Owner Backup Withholding

6. Enter the amount of total owner withholding from Schedule I, Column E or Column F .................... 6. _____________

7. Late filing penalty (see instructions) .................................................................................................. 7. _____________

8. Late payment penalty ........................................................................................................................ 8. _____________

9. Interest .............................................................................................................................................. 9. _____________

10. Add lines 6 through 9 and enter the result here. This is the sum of your total tax, penalties

and interest. .................................................................................................................................. 10. _____________

Declaration

I, the undersigned, declare that I am authorized to sign the disregarded entity return and that the return, including all

accompanying attachments, is, to the best of my knowledge and belief, true, correct and complete.

________________________________________________________________________________________________

Signature

Title

Telephone Number

Date

____________________________________________

Printed Name

164