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Form 941p-Me Loose - Pass-Through Entity Return Of Maine Income Tax Withheld From Owners - 2006

FORM 941P-ME

Loose

MAINE REVENUE SERVICES

2006

*0606250*

PASS-THROUGH ENTITY RETURN

OF MAINE INCOME TAX WITHHELD FROM OWNERS

QUARTER #

Pass-through

A. Number of payees subject to

2 0

Withholding Account Number:

pass-through entity withholding.

Period Covered:

1. Pass-through Entity Withholding for this quar-

ter (from Schedule 2, line 10) ............. 1. $

Y Y

2. Less payments (from Schedule 1, line 5)2. $

Name and Address:

3a. Amount due with this return (if line 1 minus

line 2 is positive) ............................... 3a. $

3b. Overpayment to be refunded (if line 1 minus

Name

line 2 is negative) .............................. 3b. $

Street Address

City

State

ZIP Code

Under penalties of perjury, I certify that the information contained on this return, report and attachment(s) is true and correct.

Date ___________ Signature ___________________________ Title _______________________________ Telephone _____________________

Contact person e-mail __________________________________ Paid preparer EIN:

Maine Payroll Processor License Number:

Make check payable to:

Treasurer, State of Maine

Mail return and check to:

Maine Revenue Services, P.O. Box 9118, Augusta, ME 04332-9118

For the Third Quarter Only: please check if applicable:

I file my return electronically or my return is prepared by a tax preparer and I do not need Maine tax forms mailed to me next year.

Cancellation Notice

4. Check here and complete this section if your business is discontinued or the requirement to withhold permanently ceases. .......................

Reason for cancellation: ________________________________________________________________________________________________

________________________________________________________________________________________________

Business sold to: ________________________________________________________

Last Payroll Date:

M M

Address: ________________________________________________________

________________________________________________________

Date Sold:

M M

Telephone: ________________________________________________________

Note: Use the Name and Address Change Form (Form 941/C1C-ME) to change your business

name or address. This form is available on-line at (click “Forms,

Publications & Applications” link, then select “Pass-Through Entity Withholding”).

Office

use only

Form 941p-Me Loose - Pass-Through Entity Return Of Maine Income Tax Withheld From Owners - 2006

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