Form 941p-Me - Pass-Through Entity Return Of Maine Income Tax Withheld From Members - 2011

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FORM 941P-ME
MAINE REVENUE SERVICES
99
PASS-THROUGH ENTITY RETURN
2011
OF MAINE INCOME TAX WITHHELD FROM MEMBERS
*11062L0*
QUARTER #
/
/
Due on or Before:
MM
DD
YYYY
Period Covered:
Pass-through Withholding Account Number:
2 0
-
2 0 1 1
2 0 1 1
/
/
/
/
to
1.
Pass-through entity withholding for this
MM
DD
YY YY
MM
DD
YYYY
.
,
,
quarter (from Schedule 2P, line 10) ..
$
Name and Address:
2.
Less payments (from Schedule 1P,
.
,
,
$
line 5) ................................................
Name
3a. Amount due with this return (if line
.
,
,
$
1 is greater than line 2) .....................
Address
3b. Overpayment to be refunded (if
.
,
,
$
line 2 is greater than line 1) .............
City
State
ZIP Code
Under penalties of perjury, I certify that the information contained on this return, report and attachment(s) is true and correct.
Signature:________________________________________________ __________________________________
Date:_______________________________
Print Name: ___________________________________________
Telephone: _____________________
Contact Person Email:______________________________
For Paid Preparers Only
Paid Preparer’s Signature:________________________________________________ Date:__________________ Telephone:__________________________________
-
Paid Preparer EIN:
Firm’s Name (or yours, if self-employed):_____________________________________
Maine Payroll Processor License Number:
Address:_______________________________________________________________
Note: Use the Business Notifi cation Change Form (Form 941BN-ME) to change your business name or address.
See Instructions for Electronic Filing and Payment Requirements and Options
If enclosing a check, make check payable to:
If not enclosing a check,
Treasurer, State of Maine
MAIL RETURN TO:
and MAIL WITH RETURN TO:
MAINE REVENUE SERVICES
MAINE REVENUE SERVICES
P.O. BOX 1065
P.O. BOX 1064
AUGUSTA, ME 04332-1064
AUGUSTA, ME 04332-1065

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