DOMESTIC EMPLOYER’S ANNUAL REPORT 
                                                             CONTINUATION SHEET 
1. ACCOUNT NUMBER    2. COUNTY CODE              3. TAX AREA 4. TAX RATE 5. NAICS CODE  6. FEDERAL I.D. NUMBER                        7. YEAR 
                                                                     %                                                                         
 
8. EMPLOYER NAME                                                                                            9. PAGE NO. 
                                                                                                             
                                                                                                                   OF      
                                                                                    DOM 
                                                                                     
                                                                                22. TOTAL WAGES PAID DURING 
20. SOCIAL SECURITY  1   2  
                      ST ND     21. EMPLOYEE NAME            ST QTR             2 NDQTR EACH QUARTER3 RDQTR             4 THQTR 
             NUMBER  INIT INIT  LAST NAME                    1
                                                                                                                                                
                                    23. PAGE TOTAL                                                                                               
TEXAS WORKFORCE COMMISSION 
AUSTIN, TEXAS 78714-9037                                                      The sum of all page totals must equal item 13 on C-3DOM 
(512) 463-2222                   
C4DOM (12/07)