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Form Rpd-41367 11 - Annual Withholding Of Net Income From A Pass-Through Entity Detail Report - 2011 Page 2

RPD-41367 11

New Mexico Taxation and Revenue Department

*119080200*

Rev. 8/9/2012

2011 Annual Withholding of Net Income

From a Pass-Through Entity Detail Report

- Supplemental Form -

PTE’s FEIN

Pass-through entity’s name

Page ______ of _______

Owner’s name,

Column 2

Column 3

Column 4

Owner’s SSN/FEIN

Owner’s share of

Tax withheld and

street address,

net income

paid by the PTE

city, state, ZIP code

Check one:

FEIN

Check if outside the U.S.

SSN

Check one:

FEIN

Check if outside the U.S.

SSN

Check one:

FEIN

Check if outside the U.S.

SSN

Check one:

FEIN

Check if outside the U.S.

SSN

Check one:

FEIN

Check if outside the U.S.

SSN

Check one:

FEIN

Check if outside the U.S.

SSN

Check one:

FEIN

Check if outside the U.S.

SSN

Check one:

FEIN

Check if outside the U.S.

SSN

Check one:

FEIN

Check if outside the U.S.

SSN

If more space is needed, print the Supplemental Form directly from

the website and attach the additional supplemental forms to the

first page of this form. Reproducing from a photocopy reduces the

Line 2. Total withholding this page.

PTW-D

readability of the bar code on scanning equipment.

Form Rpd-41367 11 - Annual Withholding Of Net Income From A Pass-Through Entity Detail Report - 2011 Page 2

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