Form 841me - Certifi Ed Visual Media Production Wage Reimbursement Application
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1
2
3Maine Revenue Services
Form 841ME
Certifi ed Visual Media Production
Wage Reimbursement Application
-
Certifi ed Production Company Name:
Federal Employer ID Number:
-
-
Address:
Production Start Date:
-
-
City:
State:
ZIP Code:
Production End Date:
1. Certifi ed Production wages paid to Maine resident individuals
$
,
,
(from Schedule 2, line 3 and Schedule 3, line 3) ........................ 1.
.00
2. Reimbursement requested for Maine resident individuals
$
,
,
(12% of line 1) ............................................................................. 2.
.00
3. Certifi ed Production wages paid to nonresident individuals
$
,
,
(from Schedule 2, line 4 and Schedule 3, line 4) ........................ 3.
.00
4. Reimbursement requested for nonresident individuals
(10% of line 3) ............................................................................. 4.
$
,
,
.00
5. Total Certifi ed Production wages (line 1 plus line 3) ................... 5.
$
,
,
.00
6. Total reimbursement requested (line 2 plus line 4) ..................... 6.
$
,
,
.00
NOTE:
Complete and attach Schedule 2. Also complete and attach Schedule 3 if
required. Reimbursement requests will not be processed until a properly
completed Schedule 2 and/or Schedule 3 are received by Maine Revenue
Services. Attach a copy of the certifi ed visual media production report
submitted to the Department of Economic and Community Development.
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements and to the best of my
knowledge and belief they are true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which
preparer has any knowledge.
Signature: ______________________________________________
Date:
-
-
Title: _____________________________________________
Telephone:
-
-
Paid Preparer’s EIN:
-
Contact Person’s Name: _____________________________
Telephone:
-
-
Contact Person’s Email address: ___________________________________________________
Mail To:
Maine Revenue Services
P.O. Box 1064
Augusta, ME 04332-1064
Rev. 10/12
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