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

2012

MAINE REVENUE SERVICES

Pass-through Entity Withholding

FORM 941E-ME

Exemption Form

*1206243*

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:

Federal Employer ID Number:

Address:

Telephone Number:

City:

State:

ZIP Code:

This is a request for exemption for 2012 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 under Exemption Breakdown. Check all boxes that apply. See instructions

for a description of the qualiﬁ ed exemptions. If all nonresident members fall under an automatic exemption, 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, 2012. 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

Partnership

Automatic exemption

Number of Members:

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

Number of Members:

S corporation

Composite ﬁ ling (see instructions)