Form 841me - Certified Visual Media Production Wage Reimbursement Application Page 2
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5SCHEDULE 2 (FORM 841ME) -- Certifi ed Production Company Employees and
Non-Employee Performing Artists
Certifi ed Production
Company Name:
_______________________________________________________________________
/
/
/
/
___________________________
______
______
____________
______
______
____________
Federal Entity ID Number
Production Start Date
Production End Date
List below information relating to amounts claimed on Form 841ME, lines 1 and 3. (See instructions)
Column 1
Column 2
Column 3/4
Column 5
Column 6
Employee or Performing
Social Security Number
Nonresident/
# of Days
Certifi ed Production
Artist Name
Non-employee
Worked in
Wages
Performing Artist
Maine
3
4
□ □
$
.00
a.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
b.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
c.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
d.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
e.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
f.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
g.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
h.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
i.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
j.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
k.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
l.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
m. ________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
n.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
o.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
p.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
□ □
$
.00
q.
________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
_______
__________________
$
.00
1. Total resident certifi ed production wages this page .................................................... 1.
__________________________________
$
.00
2. Total nonresident certifi ed production wages this page .............................................. 2.
__________________________________
3. Total resident certifi ed production wages for all Schedule 2 pages
$
.00
(also enter on Form 841ME, line 1) ........................................................................... 3.
__________________________________
4. Total nonresident certifi ed production wages, all Schedule 2 pages
$
.00
(also enter on Form 841ME, line 3)............................................................................ 4.
__________________________________
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