Form 41-136a - Iowa Income Of Nonresidents Subject To Withholding - Iowa Department Of Revenue

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Iowa Department of Revenue
Iowa Income of Nonresidents Subject to Withholding
Annual Report of Purchases from Nonresidents
of Agricultural Commodities or Products with an Iowa Source
for the calendar year of ________________ (to be filed before April 1 of following year)
Reporting Company: _____________________________________________________
Address: ______________________________________________________________
Telephone: _____________________________________
Name of Nonresident Seller
Home Address
Social Security County Code
Total Dollar
(Last, First, Middle Initial)
(street or PO Box)
Number
for
Payments Made
(city, state, Zip)
Iowa Source
During the Year
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41-136a (1/24/05)

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