Form Trd-31109 - Employer'S Quarterly Wage, Withholding And Workers' Compensation Fee Report Page 2

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TRD-31109
Rev. 01/13/2012
STATE OF NEW MEXICO
TAXATION AND REVENUE DEPARTMENT
Page _______ of ________
EMPLOYER'S QUARTERLY WAGE, WITHHOLDING AND
WORKERS' COMPENSATION FEE REPORT - Supplemental Schedule
Quarter ending: ______________________
Employer's name
Federal employer's account number (FEIN)
Use this schedule if additional space is needed when filing Form TRD-31109, Employer's Quarterly Wage, Withholding
and Workers' Compensation Fee Report. Attach all pages of the supplemental schedule to Form TRD-31109 and mail it
to the address on the front page of the form. A quality photocopy of the supplemental schedule may be submitted to the
Department.
1.
EMPLOYEE SOCIAL
2.
EMPLOYEE NAME
3.
GROSS WAGES FOR
4.
STATE INCOME
5.
WC FEE DUE
SECURITY NUMBER
(Last, first and middle initial)
THIS QUARTER
TAX WITHHELD
Enter total of columns 3, 4 and 5, this page.

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