M-3                                                      MASSACHUSETTS DEPARTMENT OF REVENUE
                         RECONCILIATION OF MASSACHUSETTS INCOME TAXES WITHHELD FOR EMPLOYERS FILING QUARTERLY
W1,R                                                     YOU MUST FILE THIS FORM EVEN THOUGH NO TAX MAY BE DUE.
FEDERAL IDENTIFICATION NUMBER              BE SURE THIS FORM COVERS       FOR YEAR
                                                THE CORRECT PERIOD                                             1. TOTAL NUMBER EMPLOYED
                                                                                                                  DURING THE YEAR
            IF INCORRECT, SEE INSTRUCTIONS. DO NOT ALTER.
BUSINESS NAME                                                                                                  2. TOTAL NUMBER OF FORMS W-2
IF ANY                                                                                                            ENCLOSED
INFOR-
MATION ISBUSINESS ADDRESS                                                                                      3. TOTAL MASSACHUSETTS TAX
                                                                                                                  WITHHELD AS SHOWN ON
INCORRECT,                                                                                                        FORMS W-2
CITY/TOWNSEE                                    STATE              ZIP                                         4. TOTAL AMOUNT WITHHELD
INSTRUC-                                                                                                          PER LINE 3 OF QUARTERLY
                                                                                                                  RETURNS (from reverse)
TIONS.
            Check here if this is a final return.
                                                                                                               5. TOTAL AMOUNT REMITTED
                                                                                                                  (from reverse)
                                                                                                               Explain on the back of this form any difference between the amounts shown
                                                                                                               in lines 3 and 4 and file an amended return(s) for the applicable period(s).

Due on February 28 with Forms W-2, Copy 1. Note:Do not mail Forms M-3 or W-2 with Forms M-941, M-941D
or M-941W. Mail to: Massachusetts Department of Revenue, PO Box 7015, Boston, MA 02204.
I declare under the penalties of perjury that this return (including any accompanying schedules and statements)
has been examined by me and to the best of my knowledge and belief is a true, correct and complete return.
Signature                                       Title                 Date

                         Amount withheld                 Amount 
                         (from quarterly returns, line 3)remitted         State reason for difference:
      1st quarter
      2nd quarter
      3rd quarter
      4th quarter
      Total
Enter total amounts on the front of this form.