Form Der-1 - Montana Disregarded Entity Information Return - 2012 Page 2

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Form DER-1, Page 2
SSN
OR
FEIN
Owner Backup Withholding
7. Enter the amount of total owner withholding from Schedule I, Column E or Column F ........... 7.
00
8. Late fi ling penalty (see instructions) ......................................................................................... 8.
00
9. Late payment penalty (see instructions) ................................................................................... 9.
00
10. Interest (see instructions) ....................................................................................................... 10.
00
11. Add lines 7 through 10 and enter the result here. This is the sum of your total tax,
penalties and interest. ......................................................................................................... 11.
00
This tax return has to be signed by a partner, limited liability company member manager, president, vice president,
treasurer, assistant treasurer, chief accounting offi cer, fi duciary or offi cer representing the fi duciary.
Declaration – Under penalties of false swearing, I declare that I have examined this return, including accompanying
schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete.
Date
Printed Name and Title
Telephone Number
Signature
X
Questions? Call us toll free at (866) 859-2254 (in Helena, 444-6900), or TDD (406) 444-2830 for hearing impaired.
*12ED0201*
*12ED0201*

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