Form Der-1 - Montana Disregarded Entity Information Return - 2013 Page 2

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Form DER-1, Page 2
SSN
FEIN
OR
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.
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
Print/Type Preparer’s Name
Preparer’s Signature
Date
PTIN
Firm’s Name
Firm’s Address
Telephone Number
Firm’s FEIN
May the DOR discuss this tax return with your tax preparer?
Yes
No
*13ED0201*
*13ED0201*

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