Form Pt-Stm - Second Tier Pass-Through Entity Owner Statement
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1CLEAR FORM
MONTANA
PT-STM
Rev. 07-10
Second Tier Pass-Through Entity Owner Statement
Second tier pass-through entity owner information (as
First tier pass-through entity information (as shown
shown on the second tier owner’s most recent federal tax
on the fi rst tier entity’s most recent federal tax return or
return or Schedule K-1)
Schedule K-1)
Name
Name
Mailing address
Mailing address
City
State
Zip code
City
State
Zip code
FEIN ___________________________
FEIN
Second Tier Pass-Through Entity Type:
First Tier Pass-Through Entity Type:
S Corporation
S Corporation
Partnership
Partnership
Disregarded Entity
Disregarded Entity
Information About Second Tier Entity’s Owners
Part I. Please identify and give the status of each of the entity's owners (attach additional sheets if necessary)
Name
Address
SSN or FEIN
Status (see
instructions on
back for codes)
1.
2.
3.
4.
5.
6.
Part II. Please provide additional information about owners who are nonresident individuals, C corporations not doing
business in Montana, S corporations, partnerships and disregarded entities (attach additional sheets if necessary)
Name
Method of notifi cation about Montana source income (see instructions on back)
1.
2.
3.
4.
5.
6.
This statement 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
*14430101*
1443
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