Form It-2658 - Report Of Estimated Tax For Nonresident Individual Partners And Shareholders - 2012

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IT-2658
New York State Department of Taxation and Finance
Report of Estimated Tax for Nonresident
1
Page
of
Individual Partners and Shareholders
For Payments on Behalf of Nonresident Individuals Only
Due date
: April 17, 2012
June 15, 2012
September 17, 2012
January 15, 2013
( mark an X in one box )
Mark an X in the
Legal name
Employer identification number
box if filer is an
S corporation .......
Trade name of business if different from legal name above
Total number of partners/shareholders from
all Form(s) IT‑2658 and IT‑2658‑ATT
Address ( number and street or rural route; see instructions, Form IT‑2658‑I )
T
00
otal New York
source income ....
City, village, or post office
State
ZIP code
Total estimated
tax paid from all
00
Form(s) IT‑2658
Contact name
Contact phone number
and IT‑2658‑ATT
(
)
Contact e‑mail address
Allocation of estimated tax to nonresident individual partners and shareholders
( attach Form(s) IT-2658-ATT if necessary )
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 )
 
Paid preparer must complete ( see instructions )
Signature of general partner or member, elected officer, or
Date:
authorized person
Preparer’s NYTPRIN
Preparer’s signature
Sign
Preparer’s PTIN or SSN
Firm’s name ( or yours, if self-employed )
here
Date
Daytime phone number
Address
Employer identification number
(
)
Mark an X if
self‑employed
E‑mail:
Mail this form to:
NYS ESTIMATED INCOME TAX, PROCESSING CENTER, PO BOX 4123, BINGHAMTON NY 13902-4123
0411120094

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