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*030853000*

Maine Revenue Services

and

Maine Department of Labor

030853000

FORM 941/C1-ME

Combined Filing for Income Tax Withholding and Unemployment Contributions

Withholding Account No:

01-234567890

QUARTER #

UC Employer Account No:

0123456789

Name:

07-01-03 - 09-30-03

MADE UP NAME CORPORATION

Period Covered:

JOHN DOE

File On or Before:

10-31-03

Part One - Income Tax Withholding

Maine income tax withheld this quarter (Semi-weekly employers complete Schedule 1 on reverse side) ...................... 1

Less any semi-weekly payments (From Schedule 1, line 13 on reverse side.

See instructions for Schedule 1 on page 8) ..................................................................................................................... 2

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

Part Two - Unemployment Contributions Report

Seasonal Code

Check if reporting wage listing on

MAGNETIC TAPE or DISKETTE

05-15-03 - 09-30-03

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.

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 19) ............................................................... 6

DEDUCT EXCESS WAGES (SEE INSTRUCTIONS ON PAGE 7) ......................................................................... 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 (If you have been notified that your

.0581

rate has changed, enter the new rate in these boxes)

.......................................... 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.

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

FINAL

Reason for Cancellation ___________________________________________________________________________________________________

No Longer Have Employees - Effective:

Last Payroll Date:

Business Sold To: _______________________________________________

Date Sold: _______________________________________________

_______________________________________________

Note: Use the Name and Address Change Form (Form 941/C1C-ME) on page 3 to change your business name and address.

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

Make Check Payable to

report and attachment(s) is true and correct.

Treasurer, State of Maine