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Maine Revenue Services

and

030854000

Maine Department of Labor

Combined Filing for Income Tax Withholding and Unemployment Contributions

QUARTER #

FORM 941/C1-ME LOOSE

Name and Address

Withholding Account No.

UC Employer Account No.

Mo.

Day

Year

Mo.

Day

Year

Period

Covered

Part One - Income Tax Withholding

Maine income tax withheld this quarter (

) ............. 1

Semi-weekly employers complete Schedule 1 on reverse side

Less any semi-weekly Payments (From Schedule 1, line 13 on reverse side – see instructions.) ........... 2

Income tax withholding due (line 1 minus line 2) ........................................................................................... 3

OFFICE USE ONLY

Part Two - Unemployment Contributions Report

Seasonal Code

Check if reporting wage listing on

MAGNETIC TAPE or DISKETTE

Seasonal Period

1st Month

2nd Month

3rd Month

Enter in the space under each month the total of all full-time and part-time workers who worked during or received

pay reportable for unemployment insurance purposes for the payroll period which includes the 12 of each month.

................................................................... 4

If you had no employment in the payroll period, enter zero (0)

Number of female employees included on line 4. If none, enter zero (0) ................... 5

Total gross reportable wages paid this quarter (from Part Four, line 19a) ............................................ 6

DEDUCT EXCESS WAGES (SEE INSTRUCTIONS) ................................................................................... 7

NOTE: THE TAXABLE WAGE BASE IS $12,000 FOR EACH EMPLOYEE.

Taxable wages paid in this quarter (line 6 minus line 7) ......................................................................... 8

Contribution rate ....................................................................................................................................... 9

10. Contributions due (line 8 times total rate on line 9) ............................................................................... 10

Part Three - Calculate the Total Amount Due

11. Amount due with this return (line 3 plus line 10) .................................................................................. 11

CANCELLATION NOTICE

Check this box and complete the following section if your business is discontinued or payment of wages permanently ceases.

FINAL

DO NOT REPORT CHANGE FOR A SEASONAL SHUTDOWN PERIOD .................................................................................................................

Reason for Cancellation ___________________________________________________________________________________________________

No Longer Have Employees - Effective:

Last Payroll Date:

Business Sold To (name): _______________________________________________________

Date Sold: _______________________

(address): __________________________________________ Tel. #: ____________________

Make Check Payable to

Under penalties of perjury, I certify that the information contained on this return,

Treasurer, State of Maine

report and attachment(s) is true and correct.

Mail to:

Maine Revenue Services