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
                      ST  2ND    21. EMPLOYEE NAME           ST QTR             2ND QTR EACH QUARTER3RD QTR            4TH QTR 
             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)