Form NC-NA Fillable Nonresident Shareholder Agreement
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(MM DD YY)beginning (MM DD YY)and ending An S Corporation doing business in this State must file Form NC NA for each of its nonresident shareholders The form is due by the 15th CD 401S com or by calling 1 877 252 3052 Corporate Affirmation Date Nonresident Became Date of Valid S Corporation Election day of the fourth month following the first taxable period in which the S Corporation becomes subject to North Carolina income tax A form First Tax Year S Corporation Filed CD 401S for a nonresident who becomes a shareholder of the S Corporation after the initial due date must be filed by the due date of CD 401S for from the S Corporation General Instructions I affirm that: I affirm that: I am a nonresident shareholder of the S Corporation listed above I agree: To personal jurisdiction by the State of North Carolina for purposes of the collection of any unpaid income I will file and make timely payments of all taxes imposed by North Carolina on my pro rata share of income NC NA Nonresident Shareholder Agreement Nonresident Shareholder s Identifying Number Federal Employer ID Number Nonresident Shareholder s Name Address and Zip Code Corporation s Name Address and Zip Code Shareholder in S Corporation shareholder is liable for any tax not paid by the nonresident Additional forms are available from the Department s website www dornc Shareholder s Affirmation Shareholder s Tax Year Signature and Title of Officer Signature of Shareholder Title or Status taxes in connection with my tax return together with related interest and penalties The entity listed above is a nonresident of North Carolina and is a shareholder of the S Corporation listed above the year in which the nonresident became a shareholder An S Corporation that does not file the required Form NC NA for a nonresident This affirmation is binding on my heirs representatives assigns successors executors and administrators Web North Carolina Department of Revenue