Form 941me - Employer'S Return Of Maine Income Tax Withheld - 2003 Page 2
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1
2*030624000*
MAINE
REVENUE SERVICES
FORM 941ME
EMPLOYER’S RETURN OF MAINE INCOME TAX WITHHELD
030624000
NOTE: PLEASE COMPLETE THE BACK OF THIS FORM
QUARTER #
3
Due on or Before:
Withholding Account Number:
$
,
,
.
1. Maine income tax withheld for this quarter .... 1
10-31-01
01-234567890
2. Less semi-weekly payments
$
,
,
(from Schedule 1, line 5 below) ..................... 2
.
Period Covered:
$
07-01-01 - 09-30-01
,
,
3. Amount due with this return ........................... 3
.
Name:
To reduce printing and postage costs, if you have your return done by
MADE UP NAME CORPORATION INC
a tax preparer and do not need Maine tax forms and instructions
mailed to you next year, check this box ............................................... >
JOHN DOE
Under penalties of perjury, I certify that the information contained on this return, report and attachment(s)is true and correct.
Date _____________ Signature ________________________________ Title _____________________________________ Telephone __________________________
Schedule 1
Reconciliation of 900ME Voucher Payments or EFT Payments of Income Tax Withholding
For employers required to remit withholding taxes on a semi-weekly basis.
Date Wages
Amount
Check
Date Wages
Amount
Check
Date Wages
Amount
Check
Paid
Withheld
Amount
Paid
Withheld
Amount
Paid
Withheld
Amount
4. Total withholding this quarter (Enter here and on line 1 above)
5. Total semi-weekly payments remitted this quarter (Enter here and on line 2 above)
$
$
,
,
,
,
.
.
ALL EMPLOYERS, PLEASE CHECK THE ONE BOX THAT APPLIES:
I would like personalized wage listing pages next year.
I would like non-personalized (blank) wage listing pages next year.
I would like no wage listing pages next year (I have my wage listing pages printed by an approved alternate method).
CANCELLATION NOTICE
6. Check this box and complete the following section if your
Make check payable to:
business is discontinued or payment of wages permanently ceases.
FINAL
Treasurer, State of Maine
Reason for cancellation ______________________________________________________________________________
Mail to:
Maine Revenue Services
-
-
P.O. Box 1061
Last Payroll Date:
Business Sold to: __________________________________________
Augusta, ME 04332-1061
Mo.
Day
Year
(address): ________________________________________________
Date Sold: ___________________________
Telephone: _______________________________________________
Office use only
Note: Use the Name and Address Change Form (Form 941/C1C-ME) on page 3 to change your business name or address.
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