DOMESTIC EMPLOYER’S ANNUAL REPORT 
      C AE                                                       ONTETNII TNSUHO 
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
             NUMBER   INIT INIT  LAST NAME                       1
                       ST 2 21.ND EMPLOYEENAME                    ST QTR 2  ND QTR      EACH QUARTER3RD QTR    4TH QTR 
                                                                                                             
                                                  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)