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941 X Form

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1/4 Personal Information

Year of filing

Check the type of return you’re correcting * i

941

941-SS

Check the ONE quarter you’re correcting * i

Q1 - January, February, March

Q2 - April, May, June

Q3 - July, August, September

Q4 - October, November, December

Enter the calendar year of the quarter you’re correcting * i

Enter the date you discovered errors * i

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

Print your name here i

Print your title here i

Best daytime phone i

Signature i

Date i

Are you a paid preparer?

Yes

Preparer's Full Name

Preparer signature

Date Signed

Preparer Occupation

PTIN *

Check if self-employed

Firm's Name

Country

Address i

Apt/Ste No

City

State

Zip Code

Firm's EIN

Firm's Phone Number

4/4 Submit

I agree that I will not use this site for any illegal purposes

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941 X Form

1/4 Personal Information

Part 1: Process Selection

Part 2: Complete the certifications

Part 3: Enter the corrections for this quarter.

4/4 Submit

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