Form 941a-Me Loose - Amended Return Of Income Tax Withholding - 2005
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1FORM 941A-ME
MAINE REVENUE SERVICES
00
LOOSE
AMENDED RETURN
2005
OF MAINE INCOME TAX WITHHOLDING
*0506320*
to
Period Covered:
M M
DD
YY
M M
DD
YY
Review instructions on back before completing lines 1 through 5.
Withholding Account Number:
$
,
,
1. Withholding originally
.
reported for the quarter ................
$
,
,
2. Correct withholding
Name and Address:
.
for the quarter ..............................
$
,
,
3. Correction amount (+ or -)
.
(see instructions) ..........................
Name
$
,
,
4. Underpayment to be paid
.
(line 3 amount is negative) ...........
Street Address
$
,
,
5. Overpayment to be refunded
.
(line 3 amount is positive) ............
City
State
ZIP Code
INDIVIDUAL EMPLOYEE / MEMBER WITHHOLDING CORRECTIONS
A
B
C
D
E
F
Originally Reported
Correct
Adjustment
Employee/Member
Employee/Member
Name of
Originally Reported
(Column D minus
Social Security Number
Social Security Number
Employee/Member
Withholding
Correct Withholding
column E)
TOTALS
Under penalties of perjury, I certify that the information contained on this return and attachment(s) is true and correct. The portion of
overpayment identified on line 5 attributable to overcollected withholding tax for the current calendar year has been repaid to employees and
TOTALS
written statements have been obtained from each employee stating that the employee has not claimed and will not claim a refund or credit
of the amount of the overcollection.
Date _____________ Signature ________________________________ Title _____________________________________ Telephone __________________________
Contact person e-mail _________________________________________ Paid preparer EIN:
6. Explanation of adjustments: _______________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________ (check if continued on back of form ____ )
Make check payable to:
Mail return and check to:
Office
Treasurer, State of Maine
Maine Revenue Services, P.O. Box 1061, Augusta, ME 04332-1061
use only
PD
Rev. 12/04
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