Form 941af-Me - Nonresident Member Affi Davit And Agreement To Comply With Maine Income Tax

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FORM 941AF-ME
Maine Revenue Services
Nonresident Member Affi davit and Agreement to
Comply with Maine Income Tax
1. I am a nonresident member of a pass-through entity with Maine-source income.
___________________________________________________________
Member’s name:
_________________________________________________________
2. Member’s address:
: __________________________
3. Member’s social security number or taxpayer identifi cation number
4. The pass-through entity for which this affi davit and agreement applies:
____________________________________________________
Pass-through entity’s name:
__________________________________________________
Pass-through entity’s address:
Pass-through entity’s taxpayer identifi cation number: ___________________________________________
5. I agree that I am subject to the personal jurisdiction of the State of Maine and its agencies and courts for the purpose
of determining and collecting Maine income taxes due, including estimated taxes, together with any related
interest and penalties.
6. I agree to timely fi le appropriate returns and make payment of all Maine income taxes, including estimated payments,
required by law. If the entity completing this affi davit (member listed in item 1) is an upper-tier pass-through entity, the
entity agrees to withhold Maine income tax from its members in accordance with 36 M.R.S.A. § 5250-B and MRS
Rule 803.06 or to obtain exemptions from the withholding requirement in accordance with MRS Rule 803.06 and the
instructions for Form 941P-ME.
7. This agreement is binding upon my heirs, representatives, assigns, successors, executors and administrators.
8. I understand and agree that Maine Revenue Services may revoke the pass-through entity withholding exemption at
any time it determines that I am not abiding by the terms of this agreement.
9. I authorize Maine Revenue Services to disclose to the entity named in paragraph 4 of any failure on my part to timely
fi le appropriate returns and/or make payment of all Maine income taxes required by law.
Under penalties of perjury, I declare that I have examined this form and statements and to the best of my knowledge
and belief they are true, correct and complete.
________________________________________________________________________________
Signature of member
Date
________________________________________________________________________
Printed name
This affi davit must be held by the pass-through entity. It is not necessary to submit a new affi davit each year. The affi davit will remain in force continu-
ously as long as the member retains an ownership interest in the pass-through entity and it is not revoked. The affi davit is automatically revoked if for
any reason the pass-through entity does not include the nonresident member on the Schedule 3P submitted with the Maine annual pass-through en-
tity return (Form 941P-ME). A revoked affi davit must be retained by the pass-through entity for at least three years after the year in which it is revoked.
Rev. 9/12

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