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MAINE REVENUE SERVICES

2016

PASS-THROUGH ENTITY RETURN

FORM 941P-ME

OF MAINE INCOME TAX WITHHELD FROM MEMBERS

March 15, 2017

*16941P0*

Due on or Before:

01 01 2016 - 12 31 2016

Federal Identiﬁ cation No:

Period Covered:

Check here if you ﬁ led: federal Form 1065

federal Form 1120S:

Check this box and complete Schedule 3P if you are claiming the Compliant

Taxpayer or Composite Filing exemption from pass-through entity withholding

for any non-resident member. See Schedule 3P instructions ...........................

Amended return:

Check here if your address

changed:

B. Total number of non-resident members (see instructions) __________

Pass-through entity

withholding for this year

(from Schedule 2P, line 12) ....

Name

Estimated Payments ..............

3a. Amount due with this return

(line 1 minus line 2, if line 1

Address

is greater than line 2)...............$

3b. Overpayment to be refunded

(line 2 minus line 1, if line 2

City

State

ZIP Code

is greater than line 1)..............

Check here if you have an ownership interest in or you received Maine source income reported on Schedule K-1 from another pass-through

entity. If checked, attach a statement that includes the name and FEIN of the other pass-through entity(ies).

Schedule 1P- Entity Apportionment

If tax year is a fiscal year, enter

_____ /_____ /_____ to ____ / _____ /_____

tax year begin and end dates:

DD YYYY

4a. Maine

4b. Everywhere

.00

Sales

4c. Maine

5. Total Entity

.00

Apportionment

income or loss

Factor

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and

belief, they are true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Signature:

Date:

Print Name:

Telephone:

Contact Person Email:

For Paid Preparers Only

Paid Preparer’s Signature:

Date:

Telephone:

Firm’s Name (or yours, if self-employed):

Paid Preparer EIN:

Address:

See pages 3 and 4 of the instructions for electronic ﬁ ling and payment requirements and options.

MAILING INSTRUCTIONS FOR THOSE NOT FILING ELECTRONICALLY

If enclosing payment, make check payable to: Treasurer, State of Maine and mail with return to: Maine Revenue Services, P.O. Box 1065, Augusta, ME 04332-1065.

If not enclosing payment, mail return to: Maine Revenue Services, P.O. Box 1064, Augusta, ME 04332-1064.

Physical location (for overnight delivery only): Maine Revenue Services, 51 Commerce Drive, Augusta, ME 04330.