FORM 941A-ME Loose
MAINE REVENUE SERVICES
2006
00
AMENDED RETURN
*0606320*
OF MAINE INCOME TAX WITHHOLDING
/
/
/
/
to
Period Covered:
MM
DD
YY
MM
DD
YY
Review instructions on back before completing lines 1 through 5.
Withholding Account Number:
Name and Address:
1. Withholding originally
,
,
.
$
reported for the quarter ................
2. Correct withholding
Name
,
,
.
$
for the quarter ..............................
3. Amount of Adjustment (+ or -)
,
,
.
$
(see instructions) ..........................
Street Address
4. Underpayment to be paid
$
,
,
.
(line 3 amount is negative) ...........
5. Overpayment to be refunded
City
State
ZIP Code
$
,
,
.
(line 3 amount is positive) ............
INDIVIDUAL EMPLOYEE / MEMBER WITHHOLDING CORRECTIONS
A
B
C
D
E
F
Originally Reported
Correct
Adjustment
Employee/Payee/Member
Employee/Payee/Member
Name of
Originally Reported
(Column D minus
Social Security Number
Social Security Number
Employee/Payee/Member
Withholding
Correct Withholding
column E)
or FEIN
or FEIN
TOTALS
If this Form 941A-ME is received after the end of the tax year to which it applies, the section below must be completed. Please check each box that
applies and attach a detailed explanation of the adjustments including all supporting documentation to this return.
I certify that none of the overpayment identified above is attributable to income taxes withheld from employees, payees or members.
I certify Forms W-2C or corrected 1099 statements have been issued to employee(s), payee(s) or members(s) as listed on this Form
941A-ME. I am enclosing the corrected statements to verify my refund request.
I am enclosing an amended W-3ME Reconciliation of Maine Income Tax Withheld to reflect changes made on Form 941A-ME.
Note: Pursuant to 36 M.R.S.A. § 5276, if there is an overpayment of tax required to be deducted and withheld under § 5250, a refund shall be made
to the employer only to the extent that the overpayment was not deducted and withheld by the employer.
Under penalties of perjury, I certify that the information contained on this return and attachment(s) is true and correct, and that portion of
overpayment identified on line 5 attributable to overcollected withholding tax for the current calendar year has been repaid to employees and
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:
Maine Payroll Processor License Number:
6. Explanation of adjustments: _______________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
___________________________________________________________________ (check if continued on back of form ____ )
Office
PD
Make check payable to:
Mail return and check to:
use only
Treasurer, State of Maine
Maine Revenue Services, P.O. Box 1061, Augusta, ME 04332-1061
Rev. 12/05