Form 841me - Certified Visual Media Production Wage Reimbursement Application Page 3

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SCHEDULE 3 (FORM 841ME) -- Temporary Employee-Leasing Company Employees
Certifi ed Production
Company Name:
_____________________________________________________________________________________________________
/
/
/
/
___________________________
______
______
____________
______
______
____________
Federal Entity ID Number
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
Column 5
Employee Name
Social Security Number
Nonresident
# of Days
Certifi ed Production
Worked in
Wages
Maine
□
$
.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 3 pages
$
.00
(also enter on Form 841ME, line 1) ............................................................................................ 3.
_______________________________
4. Total nonresident certifi ed production wages, all Schedule 3 pages
$
.00
(also enter on Form 841ME, line 3) ............................................................................................ 4.
_______________________________

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