1/4 Personal Information

Year of filing

Report for the Quarter *

Employer Identification Number * i

Name (not your trade name) * i

Trade Name (if any) i

Country

Address i

Apt/Ste No

City

State

Zip Code

2/4 Tax Information

Part 1: Answer these questions for this quarter.

Line 1: Number of employees who received wages, tips, or other compensation for the pay period, including: June 12 (Quarter 2), Sept. 12 (Quarter 3), or Dec. 12 (Quarter 4) * i

Line 2: Wages, tips, and other compensation * i

Line 3: Federal income tax withheld from wages, tips, and other compensation * i

Line 4: Check if there’s no wages, tips, and other compensation are subject to social security or Medicare tax.

Line 5A: Taxable social security wages i

Line 5B: Taxable social security tips i

Line 5C: Taxable Medicare wages & tips i

Line 5D: Taxable wages & tips subject to Additional Medicare Tax withholding i

Line 5F: Section 3121(q) Notice and Demand—Tax due on unreported tips i

Line 7: Current quarter’s adjustment for fractions of cents i

Line 8: Current quarter’s adjustment for sick pay i

Line 9: Current quarter’s adjustments for tips and group-term life insurance i

Line 11: Qualified small business payroll tax credit for increasing research activities i

Line 13: Total deposits for this quarter, including overpayment applied from a prior quarter and overpayments applied from Form 941-X, 941-X (PR), 944-X, or 944-X (SP) filed in the current quarter i

Check one refund option:

Apply to next return

Send a refund

4/4 Submit

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941 Form

1/4 Personal Information

2/4 Tax Information

Part 1: Answer these questions for this quarter.

3/4 Certification

Part 2: Tell us about your deposit schedule and tax liability for this quarter

Tax Liability

Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank.

Part 4: May we speak with your third-party designee?

Part 5: Sign here. You MUST complete all three pages of Form 941 and SIGN it

941-V: Payment Voucher

4/4 Submit

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