Form Nc-Na - Nonresident Shareholder Agreement

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NC-NA
Nonresident Shareholder Agreement
CD-401S
North Carolina Department of Revenue
Web
1-09
Nonresident Shareholder’s Identifying Number
Federal Employer ID Number
Nonresident Shareholder’s Name, Address, and Zip Code
Corporation’s Name, Address, and Zip Code
Date Nonresident Became
Shareholder in S Corporation
Date of Valid S Corporation Election
Shareholder’s Tax Year
First Tax Year S Corporation Filed CD-401S
(MM-DD-YY)
beginning
(MM-DD-YY)
and ending
Shareholder’s Affirmation
I affirm that: I am a nonresident shareholder of the S Corporation listed above.
I will file and make timely payments of all taxes imposed by North Carolina on my pro rata share of income
from the S Corporation.
To personal jurisdiction by the State of North Carolina for purposes of the collection of any unpaid income
I agree:
taxes in connection with my tax return, together with related interest and penalties.
This affirmation is binding on my heirs, representatives, assigns, successors, executors, and administrators.
Signature of Shareholder
Title or Status
Corporate Affirmation
I affirm that:
The entity listed above is a nonresident of North Carolina and is a shareholder of the S Corporation listed above.
Signature and Title of Officer
Date
General Instructions
An S Corporation doing business in this State must file Form NC-NA for each of its nonresident shareholders. The form is due by the 15th
day of the fourth month following the first taxable period in which the S Corporation becomes subject to North Carolina income tax. A form
for a nonresident who becomes a shareholder of the S Corporation after the initial due date must be filed by the due date of CD-401S for
the year in which the nonresident became a shareholder. An S Corporation that does not file the required Form NC-NA for a nonresident
shareholder is liable for any tax not paid by the nonresident. Additional forms are available from the Department’s website,
com, or by calling 1-877-252-3052.

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