Form 841me - Certifi Ed Visual Media Production Wage Reimbursement Application Page 3
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1
2
3SCHEDULE 3 (FORM 841ME) --
Temporary Employee-Leasing Company Employees
Certifi ed Production
Company Name:
-
-
-
-
-
Federal EIN:
Production Start Date:
Production End Date:
-
Employee Leasing Company Name:
EIN:
List below information relating to amounts claimed on Form 841ME, lines 1 and 3. (See instructions)
Column 1
Column 2
Column 3
Column 4
Employee Name
Social Security Number
Nonresident
Certifi ed Production Wages
,
a.
___________________
-
-
.00
,
-
-
b.
___________________
.00
,
c.
___________________
-
-
.00
,
-
-
d.
___________________
.00
,
e.
___________________
-
-
.00
,
f.
___________________
-
-
.00
,
-
-
g.
___________________
.00
,
h.
___________________
-
-
.00
,
-
-
i.
___________________
.00
,
j.
___________________
-
-
.00
,
k.
___________________
-
-
.00
,
-
-
.00
l.
___________________
,
m. ___________________
-
-
.00
,
-
-
n.
___________________
.00
,
o.
___________________
-
-
.00
,
p.
___________________
-
-
.00
,
,
1. Total resident payments this page ..................................................................1.
.00
,
,
2. Total nonresident payments this page ............................................................2.
.00
,
,
.00
3.
3.
Total resident payments for all Schedule 3 pages (also enter on Form 841ME, line 1) .....
,
,
4.
4.
.00
Total nonresident payments, all Schedule 3 pages (also enter on Form 841ME, line 3) .....
Rev. 10/12
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