Form 941e-Me - Pass-Through Entity Withholding Exemption - 2009

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FORM 941E-ME
MAINE REVENUE SERVICES
99
2009
Pass-through Entity Withholding
*0906243*
Exemption Form
To exempt nonresident Maine-source income from pass-through entity withholding.
This form must be submitted prior to the fi rst withholding payment deadline for which it is to be effective.
-
Entity Name:
Entity Federal Identifi cation Number:
-
-
Address:
Telephone Number:
City:
State:
ZIP Code:
This is a request for exemption for 2009 from the Maine pass-through entity withholding requirement for nonresident members of a pass-
through entity with Maine-source income. The request is based on the reason(s) checked below. Check all boxes that apply. See instructions
for a description of the qualifi ed exemptions. If all nonresident members fall under one or more automatic exemptions, you are not required
to fi le this form (see instructions). If required to fi le this form, mail it separately from Form 1065ME/1120S-ME.
Form 941E-ME is due January 31, 2009. MRS will accept exemption forms fi led after this due date; however, the exemption will not take
effect until the quarter during which Form 941E-ME is fi led. The entity may be held liable for any taxes that were required to be withheld, or
for interest and penalties on taxes that should have been withheld.
If you are registered to fi le a Maine pass-through entity withholding return, but all of the members are exempt from the pass-through entity
withholding requirement, check this box, and Maine Revenue Services will cancel your pass-through entity withholding account.
ENTITY TYPE
Exemption Breakdown
,
Automatic exemption
Number of Members:
Partnership
Compliant taxpayer(s) - attach Form 941LM-ME
Number of Members:
,
S corporation
,
Composite fi ling (see instructions)
Number of Members:
LLC
Requested - Only for members who do not
Number of Members:
,
qualify for any of the above (see instructions)
,
Nonexempt nonresident members*
Number of Members:
* Do not submit this form if the number of nonexempt
,
Total Nonresident Members:
members equals the total nonresident members.
You must register and withhold.
I certify that I have collected a Compliant Taxpayer Affi davit from each member participating in the compliant taxpayer group and a Composite Filing
Participation Statement from each member participating in the composite fi ling.
Under penalties of perjury, I declare that I have examined this form 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.
Offi cer’s Signature: _______________________________________________
Title: __________________________ Date:________________
Offi cer’s Printed Name: ___________________________________________
Preparer’s Signature: _____________________________________________
Date: __________________________
Preparer’s Printed Name: __________________________________________
Mail to:
Maine Revenue Services
P.O. Box 9118
Augusta, ME 04332-9118
Offi ce Use Only
Rev. 11/08

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