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Form 941cf-Me - Nonresident Member Agreement To Participate In A Composite Filing Of Maine Income Tax For Tax Year 2004

Maine Revenue Services

Nonresident Member Agreement to Participate in

a Composite Filing of Maine Income Tax

for Tax Year 2004

FORM 941CF-ME

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 agreement applies:

The entity’s name is: _________________________________________________________________________

The entity’s address is: _______________________________________________________________________

_________________________________________________________________________________________

The entity’s taxpayer identification number is: _____________________________________________________

5. 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.

6. I agree to participate in the composite filing for tax year 2004 by the entity listed in 4 above.

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 certify that I earn no Maine-source income other than through the entity listed in paragraph 4.

(Note: this does not exclude you from participating in another composite return.)

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

Date

_________________________________________________________________________________________

Printed name

Rev. 1/04

Form 941cf-Me - Nonresident Member Agreement To Participate In A Composite Filing Of Maine Income Tax For Tax Year 2004