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Form 482.0(C) - Composite Return Partners And Individual Members Of Partnerships And Limited Liability Companies Page 3

INDIVIDUAL PARTNER OR MEMBER

Schedule I (C)

COMPOSITE RETURN

Rev. 05.13

2012

Affidavit

(To be filed with Form 482(C) or Form 480.20(C))

Taxable year beginning on ______________________, ________ and ending on _____________________, ________

Social Security Number

Name

Personal Circumstances

Address

Citizen of the United States:

Yes

If yes:

Personal Exemptions (1 if single, 2 if married) _____

Number of dependents .................................. _____

The undersigned taxpayer under oath, being duly sworn, hereby certifies and agrees as follows:

My name, social security number, address and personal circumstances are as stated above.

I was not a resident of Puerto Rico during any part of the captioned taxable year.

I am a partner or member of the pass-through entity described in Item 4.

Name of Entity: ______________________________________________________________________________________________________

Entity’s Employer Identification Number: ____________________________________________________________________________________

Entity’s address: ______________________________________________________________________________________________________

___________________________________________________________________________________________________

Type of Entity:

Partnership engaged in trade or business in Puerto Rico

Limited liability company (LLC)

Pass-thru entity member of a Partnership engaged in trade or business in Puerto Rico (Resident Partnership)

Name of the Resident Partnership ___________________________________________________

Employer Identification Number (EIN) of the Resident Partnership __________________________

Taxpayer’s participation in the entity’s income, gains or losses: _____________%

The type of income for which this affidavit and agreement applies is:

Distributed or undistributed Puerto Rico income from a partnership

Distributed or undistributed Puerto Rico income from an LLC taxed as a partnership

I have no other Puerto Rico source income or source of income taxable in Puerto Rico other than from the entity described in item 4.

I agree to be included in the composite return to be filed by the entity described in item 4, and that any refund resulting thereof be disbursed to said entity.

This affidavit applies for the captioned taxable year.

The undersigned understands that any false statement contained herein could be punished by fine, imprisonment or both.

Under penalties of perjury, I declare that I have examined this affidavit and agreement and, to the best of my knowledge and belief, it is true, correct

and complete.

Signature of partner or member

Date

Retention Period: Ten (10) years