Montana Form Pt-Stm - Second-Tier Pass-Through Entity Owner Statement And Waiver Request (For Tax Years 2011 And Earlier) Page 2

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Pass-Through Entity Owner Information (third-tier, fourth-tier, etc.)
Name
Will this owner file a
FEIN of the entity that this
Entity Type and Identification
Residency
Street Address or PO Box
Tier
MT tax return for the
owner has an ownership
Number (FEIN or SSN)
Code (R/N)
City | State | Zip Code
current tax year?
interest in
1
Entity Type (see instructions)
R
Yes
-
FEIN
No
N
Don’t Know
_________% of ownership
SSN
2
Entity Type (see instructions)
R
Yes
-
FEIN
No
N
Don’t Know
_________% of ownership
SSN
3
Entity Type (see instructions)
R
Yes
-
FEIN
No
N
Don’t Know
_________% of ownership
SSN
4
Entity Type (see instructions)
R
Yes
-
FEIN
No
N
Don’t Know
SSN
_________% of ownership
5
Entity Type (see instructions)
R
Yes
-
FEIN
No
N
Don’t Know
SSN
_________% of ownership
6
Entity Type (see instructions)
R
Yes
-
FEIN
No
N
Don’t Know
SSN
_________% of ownership
7
Entity Type (see instructions)
R
Yes
-
FEIN
No
N
Don’t Know
SSN
_________% of ownership
8
Entity Type (see instructions)
R
Yes
-
FEIN
No
N
Don’t Know
SSN
_________% of ownership
9
Entity Type (see instructions)
R
Yes
-
FEIN
No
N
Don’t Know
_________% of ownership
SSN
10
Entity Type (see instructions)
R
Yes
-
FEIN
No
N
Don’t Know
_________% of ownership
SSN
*11EB0101*
*11EB0101*

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