Form 841me - Certified Visual Media Production Wage Reimbursement Application
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5Maine Revenue Services
Form 841ME
Certifi ed Visual Media Production
Wage Reimbursement Application
____________________________________________________________________________________
________________________
Certifi ed Production Company Name
Federal Employer ID Number
____________________________________________________________________________________
Name of Production
____________________________________________________________________________________
________________________
Address
Production Start Date
______________________________________
____________
______________________
________________________
City
State
ZIP Code
Production End Date
1.
Certifi ed production wages paid to Maine resident individuals
$
.00
(from Schedule 2, line 3 and Schedule 3, line 3) .............................. 1.
_____________________________________
2.
Reimbursement requested for Maine resident individuals
$
.00
(12% of line 1) .................................................................................. 2.
_____________________________________
3.
Certifi ed production wages paid to nonresident individuals
$
.00
(from Schedule 2, line 4 and Schedule 3, line 4) .............................. 3.
_____________________________________
4.
Reimbursement requested for nonresident individuals
$
.00
(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.
_____________________________________
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. 08/15
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