Form 941cf-Me - Nonresident Member Affidavit And Agreement To Participate In A Composite Filing Of Maine Income Tax

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FORM 941CF-ME
Maine Revenue Services
Nonresident Member Affi davit and Agreement to
Participate in a Composite Filing of 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 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 participate in composite income tax fi lings by the entity listed in paragraph 4 above.
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 certify that I earn no Maine-source income other than through the entity listed in paragraph 4. (Note: this does not
exclude you from participating in another composite return.)
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 af-
fi davit will remain in force continuously 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 Schedule 3P submitted with the Maine annual pass-through entity 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. 09/12

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