Form 4m - Wisconsin Combined Group Member - Level Data - 2011

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4M
Form
Wisconsin Combined Group
2011
Member - Level Data
Wisconsin Department
File with Wisconsin Form 4
of Revenue
Designated Agent of Combined Group
A Designated Agent’s FEIN
Name of Combined Group Member to Which This Form Applies
B Member’s FEIN
Number and Street
Suite Number
C Business Activity (NAICS) Code
ZIP (+ 4 digit suffix if known)
City
State
D State of Incorporation
and
Year
Enter abbreviation
of state in box, or
C
C
Y
Y
F Period Included in This Return
E Member’s Taxable Year End
if a foreign country,
enter below.
M M
D
D
M M
D
D
C
C
Y
Y
M M
D
D
C
C
Y
Y
G
Check
()
if this member was excluded from a combined group in another state because it was not considered engaged in a unitary business.
If checked, identify the applicable state(s) and explain on an attached statement.
H
Check
()
if this member used a multiple factor apportionment formula as provided on Form 4A-2.
if for the period included in this return, the member filed a separate Wisconsin return or
I
Check
()
was included in the combined return of another group for items not included in this combined return.
Enter the FEIN of the return under which those items were reported:
J
Check
()
if the member is a(n): 1
Insurance company
2
Tax exempt corporation
K1 Check
()
if applicable:
1
First return - new corporation or entering Wisconsin
3
Joined group during year
5
Short period - change in accounting method
2
Final return - corporation dissolved or withdrew
4
Left group during year
6
Short period - stock purchase or sale
K2 Did you file federal Schedule UTP – Uncertain Tax Position statement with the Internal Revenue Service?
Yes
No If yes, enclose federal Schedule UTP with your Wisconsin tax return.
 (1000)
 –1000
NOT LIKE THIS
NO COMMAS; NO CENTS
ENTER NEGATIVE NUMBERS LIKE THIS
Part I
Member’s Share of Form 4 Items
L1 Line 9: Combined unitary income (= Form 4, line 7 x member’s percentage from Form 4A, Part II.
.00
If this is a 100% Wisconsin group, see instructions and complete line L2 if applicable.) . . . . . . . . . . . L1
.00
L2 100% Wisconsin groups: Adjustment for current year loss offset (see instructions) . . . . . . . . . . . . . . . L2
.00
M
Line 10: Wisconsin net nonapportionable and separately apportioned income (from Form 4N, line 14) M
.00
N
Line 12: Net capital loss adjustment (from Form 4CL, Part I, line 9e) . . . . . . . . . . . . . . . . . . . . . . . . .
N
O
Line 14: Loss adjustment for insurance companies (from Schedule 4I, line 24). . . . . . . . . . . . . . . . . .
O
.00
.00
P
Line 17: Wisconsin net business loss carryforward (from Part II, line 15 on page 2 of this form) . . . .
P
.00
Q
Line 21: Gross tax (generally = 7.9% x (lines L1 + L2 + M - N - P). See instructions.) . . . . . . . . . . . . .
Q
.00
R
Line 22: Nonrefundable credits (from Part III, line 5 on page 2 of this form) . . . . . . . . . . . . . . . . . . . .
R
S
Line 24: Economic development surcharge (if applicable, = greater of $25 or 3% of gross tax on
.00
line Q; maximum of $9,800. See instructions.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
S
T
Line 28:
If this member is not the designated agent and has separate estimated payments or
overpayments to apply to this return,
check
() after the letter “T” and complete Part IV on page
2. . . . .
T
.00
U
Line 29: Wisconsin tax withheld (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
U
For each credit, enter code from instructions and amount.
{
V
Line 30: Refundable credits
Enter total refundable credits on line V.
.00
.
.
00
00
.00
V
.00
W
Line 43: Total company gross receipts from all activities (see instructions). . . . . . . . . . . . . . . . . . . . .
W
.00
X
Line 44: Total company assets from federal Form 1120 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X
.
00
.00
Y
Lines 45 and 47: Wisconsin tangible property Y1
Wisconsin payroll Y2
Z
Line 50: Total sales, receipts, or premiums (member’s denominator from Form 4A, Part I) . . . . .
Z
.00
IC-445i
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