Form 941e-Me - Pass-Through Entity Withholding Exemption

FORM 941E-ME

MAINE REVENUE SERVICES

2009

Pass-through Entity Withholding

*0906243*

Exemption Form

To exempt nonresident Maine-source income from pass-through entity withholding.

This form must be submitted prior to the ﬁ rst withholding payment deadline for which it is to be effective.

Entity Name:

Entity Federal Identiﬁ cation Number:

Address:

Telephone Number:

City:

State:

ZIP Code:

This is a request for exemption for 2009 from the Maine pass-through entity withholding requirement for nonresident members of a pass-

through entity with Maine-source income. The request is based on the reason(s) checked below. Check all boxes that apply. See instructions

for a description of the qualiﬁ ed exemptions. If all nonresident members fall under one or more automatic exemptions, you are not required

to ﬁ le this form (see instructions). If required to ﬁ le this form, mail it separately from Form 1065ME/1120S-ME.

Form 941E-ME is due January 31, 2009. MRS will accept exemption forms ﬁ led after this due date; however, the exemption will not take

effect until the quarter during which Form 941E-ME is ﬁ led. The entity may be held liable for any taxes that were required to be withheld, or

for interest and penalties on taxes that should have been withheld.

If you are registered to ﬁ le a Maine pass-through entity withholding return, but all of the members are exempt from the pass-through entity

withholding requirement, check this box, and Maine Revenue Services will cancel your pass-through entity withholding account.

ENTITY TYPE

Exemption Breakdown

Automatic exemption

Number of Members:

Partnership

Compliant taxpayer(s) - attach Form 941LM-ME

Number of Members:

S corporation

Composite ﬁ ling (see instructions)

Number of Members:

LLC

Requested - Only for members who do not

Number of Members:

qualify for any of the above (see instructions)

Nonexempt nonresident members*

Number of Members:

* Do not submit this form if the number of nonexempt

Total Nonresident Members:

members equals the total nonresident members.

You must register and withhold.

I certify that I have collected a Compliant Taxpayer Afﬁ davit from each member participating in the compliant taxpayer group and a Composite Filing

Participation Statement from each member participating in the composite ﬁ ling.

Under penalties of perjury, I declare that I have examined this form and accompanying schedules and statements and to the best of my knowledge

and belief they are true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any

knowledge.

Ofﬁ cer’s Signature: _______________________________________________

Title: __________________________ Date:________________

Ofﬁ cer’s Printed Name: ___________________________________________

Preparer’s Signature: _____________________________________________

Date: __________________________

Preparer’s Printed Name: __________________________________________

Mail to:

Maine Revenue Services

P.O. Box 9118

Augusta, ME 04332-9118

Ofﬁ ce Use Only

Rev. 11/08

Form 941e-Me - Pass-Through Entity Withholding Exemption - 2009

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