Form Fx-21c - Combined Filing For Income Tax Withholding Only Or Withholding And Unemployment Contributions Magnetic Media Transmittal

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Maine Revenue Services
(ICESA Format)
COMBINED FILING FOR INCOME TAX WITHHOLDING ONLY OR WITHHOLDING AND UNEMPLOYMENT
CONTRIBUTIONS MAGNETIC MEDIA TRANSMITTAL FORM ME. FX-21C
Mailing Address: Maine Revenue Service, Income/Estate Tax Dept. PO Box 9103, Augusta, ME 04332-9103
Remitter Name:
Quarter:
Year:
Contact:
Telephone No.
Address:
City:
State:
Zip Code:
Remitting Agent Withholding EIN: ____________________ Volume Number: _____________________
Total Number Employer Records: ____________________ Total Record Count: __________________
Total Check Amount $_____________________________
Employer Name (for multiple employers, an attachment can be used):
UC Employer Account Number:
Federal ID Number:
Indicate the Number of Volumes Submitted by Type of Media and Format Used
275 Character
275 Character
275 Character
(ICESA)
(ICESA) Combined
(ICESA) Income Tax
Combined Tax
Tax Return with UC
Withheld and Income
Return with UC
Wage Detail
Tax Withholding
Wage & WH Detail
Listing
Reel Tape
Density: (Circle One) 1600
6250
Record Size:____________
Block Size:___________
3480 or 3490 Cartridge
3.5” Diskette
CD-Rom
Data Mode: (Circle One)
EBCDIC
ASCII –1
Other___________________________
Labels: (Circle One)
Standard
Unlabeled
Me. FX-21C (rev. 09/04)

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