Iowa Nonresident Member Composite Agreement

Nonresident Member Composite Agreement
Nonresident Member Composite Agreement (41-175)
2023 IA Nonresident Member Composite Agreement

tax.iowa.gov

This form allows a pass-through entity and its nonresident member to agree to exclude the nonresident member from the pass-through
entity’s IA PTE-C Composite Return tax payment for tax year 2023. For this agreement to be effective, this form must be completed and
signed by the nonresident member, then provided to and signed by an authorized representative of the pass-through entity, prior to the
pass-through entity’s income tax return deadline. The pass-through entity shall keep this agreement in its records and submit it to the
Department upon request. This agreement is only valid for the pass-through entity’s tax year that begins in 2023. For more information
on this form and Iowa composite taxes, visit tax.iowa.gov/iowa-composite-returns-2022.
Part I: Pass-Through Entity Information
S Corporation ☐
Partnership ☐

Estate ☐

Trust ☐

Name: _________________________________________ Federal Employer Identification Number (FEIN): _____________________
Address: ________________________________________________________ City: ______________________________________
State: ________________________ ZIP: ___________________________ Phone: ______________________________________
Part II: Nonresident Member Information (Partner, Member, Shareholder, or Beneficiary)
Name: _____________________________________________________ FEIN or Social Security Number: _____________________
Address: ________________________________________________________ City: ______________________________________
State: ________________________ ZIP: ___________________________ Phone: ______________________________________

Part III: Nonresident Member Request and Certification
I hereby request that the above-named nonresident member be excluded from the above-named pass-through entity’s IA PTE-C
Composite Return tax payment for tax year 2023. By signing this agreement, I agree that I or my organization (as applicable) will be
subject to personal jurisdiction in Iowa for the purpose of the collection of Iowa income and franchise taxes, together with related interest
and penalties, with respect to my or my organization’s distributive share of income from the above-named pass-through entity. I agree
that this form is not valid without the acknowledgement and approval of the pass-through entity. Additionally, I agree to the following:
Check the appropriate box. Financial institutions organized as pass-through entities must check boxes 3 and 4.
For individuals:
1. I am an individual and will file an Iowa income tax return and make timely payment of all Iowa income taxes, including estimated
taxes, imposed on me by Iowa with respect to my distributive share of income from the above-named pass-through entity, unless
my Iowa-source income or total net income is below the Iowa filing threshold and I am not required to file an income tax return
pursuant to Iowa Code section 422.13 ...............................................................................................................................................☐
For organizations:
2. My organization is a C corporation and it will file an Iowa income tax return and make timely payment of all Iowa income taxes,
including estimated taxes, imposed on the corporation by Iowa with respect to the corporation’s distributive share of income from
the above-named pass-through entity ................................................................................................................................................ ☐
3. My organization is a financial institution and it will file an Iowa franchise tax return and make timely payment of all Iowa franchise
taxes, including estimated taxes, imposed on the financial institution by Iowa with respect to the financial institution’s distributive
share of income from the above-named pass-through entity ............................................................................................................. ☐
4. My organization is an S corporation or partnership and it will file an Iowa income tax return and make timely payment of all Iowa
income taxes, including estimated taxes and composite taxes, imposed on the S corporation or partnership by Iowa with respect to
the organization’s distributive share of income from the above-named pass-through entity .............................................................. ☐

For fiduciaries:
5. My organization is an estate or trust and it will file an Iowa income tax return and make timely payment of all Iowa taxes, including
estimated taxes and composite taxes, imposed on the estate or trust by Iowa with respect to its distributive share of income from the
above-named pass-through entity, unless the estate’s or trust’s total taxable income is below the filing threshold and it is not required
to file an income tax return pursuant to Iowa Code section 422.14 .................................................................................................... ☐
I, the undersigned nonresident member, declare under penalties of perjury or false certificate, that I have examined this document, and,
to the best of my knowledge and belief, it is true, correct, and complete.
Signature of nonresident member or authorized representative: ________________________________________________________
Printed name and title: ___________________________________________________ Date: _______________________________
Part IV: Pass-Through Entity Acknowledgment and Approval
By signing below, the undersigned pass-through entity agrees to exclude the above-named nonresident member from the pass-through
entity’s IA PTE-C Composite Return tax payment for tax year 2023, agrees to report that exclusion on its IA PTE-C Composite Return
unless otherwise exempt from filing, and agrees to remain jointly and severally liable for any unpaid tax, penalties, and interest on the
nonresident member’s distributive share of pass-through income and that such amounts may be collected from the pass-through entity
under Iowa Code section 422.16B if the nonresident member does not abide by the terms of the agreement.
Name of pass-through entity: ___________________________________________________________________________________
Signature of pass-through entity representative: ____________________________________________________________________
Printed name and title: ___________________________________________________ Date: _______________________________

41-175 (02/13/2023)