Form 941af-Me - Nonresident Member Affidavit And Agreement To Comply With Maine Income Tax - Maine Revenue Services - 2004


Maine Revenue Services
Nonresident Member Affidavit and Agreement to
Comply with Maine Income Tax
1. I am a nonresident member of a pass-through entity with Maine-source income.
My name is: _______________________________________________________________________________
2. My address is: _____________________________________________________________________________
3. My social security number or taxpayer identification number is: _______________________________________
4. The entity for which this affidavit and agreement applies:
The entity’s name is: _________________________________________________________________________
The entity’s address is: _______________________________________________________________________
The entity’s taxpayer identification number is: _____________________________________________________
5. I agree to timely file appropriate returns and make payment of all 2004 Maine income taxes, including estimated
payments, required by law.
6. I agree that I am subject to the personal jurisdiction of the State of Maine and its agencies and courts for the purpose
of determining and collecting any 2004 Maine income taxes due, including estimated taxes, together with any related
interest and penalties.
7. This agreement is binding upon my heirs, representatives, assigns, successors, executors and administrators.
8. I understand and agree that Maine Revenue Services may revoke the pass-through entity withholding exemption at
any time it determines that I am not abiding by the terms of this agreement.
9. I authorize Maine Revenue Services to disclose to the entity named in paragraph 4 of any failure on my part to timely
file appropriate returns and/or make payment of all 2004 Maine income taxes required by law.
Under penalties of perjury, I declare that I have examined this form and statements and to the best of my knowledge and
belief they are true, correct and complete.
Signature of member
Printed name


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Parent category: Financial