Form It-2658-Att - Attachment To Report Of Estimated Tax For Nonresident Individual Partners And Shareholders - 2012 Page 2

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IT-2658-ATT (2012) (back)
Page
of
Legal name
Employer identification number
Partner’s/shareholder’s first name and middle initial
Partner’s/shareholder’s last name
Social security number (SSN)
Mailing address
Apartment number
Amount of estimated tax paid on
( number and street or rural route; see instructions )
behalf of nonresident partner or
shareholder
Percentage of ownership
City, village or post office
State
ZIP code
00
%
Partner’s/shareholder’s first name and middle initial
Partner’s/shareholder’s last name
Social security number (SSN)
Mailing address
Apartment number
Amount of estimated tax paid on
( number and street or rural route; see instructions )
behalf of nonresident partner or
shareholder
Percentage of ownership
City, village or post office
State
ZIP code
00
%
Partner’s/shareholder’s first name and middle initial
Partner’s/shareholder’s last name
Social security number (SSN)
Mailing address
Apartment number
Amount of estimated tax paid on
( number and street or rural route; see instructions )
behalf of nonresident partner or
shareholder
Percentage of ownership
City, village or post office
State
ZIP code
00
%
Partner’s/shareholder’s first name and middle initial
Partner’s/shareholder’s last name
Social security number (SSN)
Mailing address
Apartment number
Amount of estimated tax paid on
( number and street or rural route; see instructions )
behalf of nonresident partner or
shareholder
Percentage of ownership
City, village or post office
State
ZIP code
00
%
Partner’s/shareholder’s first name and middle initial
Partner’s/shareholder’s last name
Social security number (SSN)
Mailing address
Apartment number
Amount of estimated tax paid on
( number and street or rural route; see instructions )
behalf of nonresident partner or
shareholder
Percentage of ownership
City, village or post office
State
ZIP code
00
%
Partner’s/shareholder’s first name and middle initial
Partner’s/shareholder’s last name
Social security number (SSN)
Mailing address
Apartment number
Amount of estimated tax paid on
( number and street or rural route; see instructions )
behalf of nonresident partner or
shareholder
Percentage of ownership
City, village or post office
State
ZIP code
00
%
00
Page total
.....
( add last column amounts )
0422120094

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