Form 941-SS Employer's Quarterly Federal Tax Return; American Samoa,

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I.R.S. SPECIFICATIONS

7

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 941-SS, PAGE 1 of 4 (OTC)
MARGINS: TOP 13 mm (1⁄ 2 ") CENTER SIDES.
PAPER: WHITE, WRITING, SUB. 20
FLAT SIZE: 216 mm (81⁄ 2 ") x 279 mm (11")
PERFORATE: NONE

Date

Signature

O.K. to print

PRINTS: HEAD TO HEAD
INK: BLACK

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

941-SS for 2008:

Action

Revised proofs
requested

Employer’s QUARTERLY Federal Tax Return

Form
American Samoa, Guam, the Commonwealth of the Northern
(Rev. October 2008)
Mariana Islands, and the U.S. Virgin Islands
Department of the Treasury — Internal Revenue Service (77)
(EIN)
Employer identification number

—

OMB No. 1545-0029

Report for this Quarter of 2008
(Check one.)

Name (not your trade name)

1: January, February, March
Trade name (if any)

2: April, May, June

Address

3: July, August, September
Number

Street

Suite or room number

4: October, November, December
City

State

ZIP code

Read the separate instructions before you complete Form 941-SS. Please type or print within the boxes.

Delete

CAPS

Part 1: Answer these questions for this quarter.
1 Number of employees who received wages, tips, or other compensation for the pay period
including: Mar. 12 (Quarter 1), June 12 (Quarter 2), Sept. 12 (Quarter 3), Dec. 12 (Quarter 4)

1

2
3
4 If no wages, tips, and other compensation are subject to social security or Medicare tax
5 Taxable social security and Medicare wages and tips:
Column 1

.
.
.

Column 2

Check and go to line 7.

.
.
.

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5a Taxable social security wages
5b Taxable social security tips

5c Taxable Medicare wages & tips

3 .124 =
3 .124 =
3 .029 =

5d Total social security and Medicare taxes (Column 2, lines 5a + 5b + 5c = line 5d)

6

7 TAX ADJUSTMENTS. Read the instructions for line 7 before completing lines 7a through 7g.

.

5d

d

7a Current quarter’s fractions of cents
7b Current quarter’s sick pay

7c Current quarter’s adjustments for tips and group-term life insurance

7d

7e Prior quarters’ social security and Medicare taxes. Attach Form 941c

7f

d

7g Special additions to social security and Medicare. Attach Form 941c

7h TOTAL ADJUSTMENTS. Combine all amounts on lines 7a through 7g

.
.

7h

8 Total taxes after adjustments. Combine lines 5d and 7h

8

9
10
11 Total deposits for this quarter, including overpayment applied from a prior quarter

11

12 Balance due. If line 8 is more than line 11, write the difference here
For information on how to pay, see the instructions.
13 Overpayment. If line 11 is more than line 8, write the difference here
© You MUST complete both pages of Form 941-SS and SIGN it.

12

For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.

.

.
.
Check one

Apply to next return.
Send a refund.
Next ©

Cat. No. 17016Y

Form

941-SS

(Rev. 10-2008)

MAILOUT
I.R.S. SPECIFICATIONS

7

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 941-SS, PAGE 1 of 4 (Mailout)
MARGINS: TOP 13 mm (1⁄ 2 ") CENTER SIDES.
PAPER: WHITE, WRITING, SUB. 20
FLAT SIZE: 216 mm (81⁄ 2 ") x 279 mm (11")
PERFORATE: NONE

PRINTS: HEAD TO HEAD
INK: BLACK

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

941-SS for 2008:

Employer’s QUARTERLY Federal Tax Return

Form
American Samoa, Guam, the Commonwealth of the Northern
(Rev. October 2008)
Mariana Islands, and the U.S. Virgin Islands
Department of the Treasury — Internal Revenue Service (77)

OMB No. 1545-0029

Report for this Quarter of 2008
(Check one.)

1: January, February, March
2: April, May, June
3: July, August, September
4: October, November, December

Delete

Read the separate instructions before you complete Form 941-SS. Please type or print within the boxes.

CAPS

Part 1: Answer these questions for this quarter.
1 Number of employees who received wages, tips, or other compensation for the pay period
including: Mar. 12 (Quarter 1), June 12 (Quarter 2), Sept. 12 (Quarter 3), Dec. 12 (Quarter 4)

1

2
3
4 If no wages, tips, and other compensation are subject to social security or Medicare tax
5 Taxable social security and Medicare wages and tips:

Check and go to line 7.

.
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1
Column 1

5a Taxable social security wages
5b Taxable social security tips

5c Taxable Medicare wages & tips

.
.
.

Column 2

3 .124 =
3 .124 =
3 .029 =

5d Total social security and Medicare taxes (Column 2, lines 5a + 5b + 5c = line 5d)

6

.

5d

7 TAX ADJUSTMENTS. Read the instructions for line 7 before completing lines 7a through 7g.

d

7a Current quarter’s fractions of cents
7b Current quarter’s sick pay

7c Current quarter’s adjustments for tips and group-term life insurance

7d

7e Prior quarters’ social security and Medicare taxes. Attach Form 941c

7f

d

7g Special additions to social security and Medicare. Attach Form 941c

.

7h TOTAL ADJUSTMENTS. Combine all amounts on lines 7a through 7g

.
.

7h

8 Total taxes after adjustments. Combine lines 5d and 7h

8

9
10
11 Total deposits for this quarter, including overpayment applied from a prior quarter

11

12 Balance due. If line 8 is more than line 11, write the difference here
For information on how to pay, see the instructions.
13 Overpayment. If line 11 is more than line 8, write the difference here
© You MUST complete both pages of Form 941-SS and SIGN it.

12

For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.

.

.
.
Check one

Apply to next return.
Send a refund.
Next ©

Cat. No. 17016Y

Form

941-SS

(Rev. 10-2008)

7

OTC and MAILOUT

I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 941-SS, PAGE 2 of 4 (OTC)
MARGINS: TOP 13 mm (1⁄ 2 ") CENTER SIDES.
PRINTS: HEAD TO HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
FLAT SIZE: 216 mm (81⁄ 2 ") x 279 mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Name (not your trade name)

Employer identification number (EIN)

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

If you are unsure about whether you are a monthly schedule depositor or a semiweekly schedule depositor, see Pub. 80
(Circular SS), section 8.

14
15

Check one:

Line 8 is less than $2,500. Go to Part 3.
You were a monthly schedule depositor for the entire quarter. Enter your tax liability
for each month. Then go to Part 3.
Tax liability:

Month 1
Month 2
Month 3

Total liability for quarter
Total must equal line 8.
You were a semiweekly schedule depositor for any part of this quarter. Complete Schedule B (Form 941):
Report of Tax Liability for Semiweekly Schedule Depositors, and attach it to Form 941-SS.

Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank.
16

If your business has closed or you stopped paying wages

Check here, and

17

/
/
enter the final date you paid wages
.
If you are a seasonal employer and you do not have to file a return for every quarter of the year

Check here.

Part 4: May we speak with your third-party designee?
Do you want to allow an employee, a paid tax preparer, or another person to discuss this return with the IRS? See the instructions
for details.
(

Yes. Designee’s name and phone number

)

–

Select a 5-digit Personal Identification Number (PIN) to use when talking to IRS.
No.

Part 5: Sign here. You MUST complete both pages of Form 941-SS and SIGN it.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Print your
name here

Sign your
name here

Date

Print your
title here
/

Best daytime phone (

/

Paid preparer’s use only

Preparer’s
SSN/PTIN

Preparer’s signature

Date

Firm’s name (or yours
if self-employed)

EIN

Address

Phone

Page

State

2

–

Check if you are self-employed

Preparer’s name

City

)

/

(

/

)

–

ZIP code
Form

941-SS

(Rev. 10-2008)

OTC

7

I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 941-SS, PAGE 3 of 4 (OTC)
MARGINS: TOP 13 mm (1⁄ 2 ") CENTER SIDES.
PRINTS: HEAD TO HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
FLAT SIZE: 216 mm (81⁄ 2 ") x 279 mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 941-V(SS),
Payment Voucher

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Purpose of Form

Specific Instructions

Making Payments With Form 941-SS

To avoid a penalty, make your payment with Form
941-SS only if:
● Your net taxes for the quarter (line 8 on Form
941-SS) are less than $2,500 and you are paying in full
with a timely filed return or
● You are a monthly schedule depositor making a
payment in accordance with the Accuracy of Deposits
Rule. See section 8 of Pub. 80 (Circular SS), Federal
Tax Guide for Employers in the U.S. Virgin Islands,
Guam, American Samoa, and the Commonwealth of
the Northern Mariana Islands, for details. In this case,
the amount of your payment may be $2,500 or more.
Otherwise, you must deposit your taxes at an
authorized financial institution or by using the
Electronic Federal Tax Payment System (EFTPS). See
section 8 of Circular SS for deposit instructions. Do
not use Form 941-V(SS) to make federal tax deposits.
Caution. Use Form 941-V(SS) when making any
payment with Form 941-SS. However, if you pay an
amount with Form 941-SS that should have been
deposited, you may be subject to a penalty. See
Deposit Penalties in section 8 of Pub. 80 (Circular SS).
Ä

Department of the Treasury
Internal Revenue Service

Note. You must also complete the entity information
above Part 1 on Form 941-SS.

payment

Detach Here and Mail With Your Payment and Form 941-SS. Ä

OMB No. 1545-0029

Payment Voucher

Form

✁
941-V(SS)

Box 1—Employer identification number (EIN). If you
do not have an EIN, apply for one on Form SS-4,
Application for Employer Identification Number, and
write “Applied For” and the date you applied in this
entry space.
Box 2—Amount paid. Enter the amount paid with
Form 941-SS.
Box 3—Tax period. Darken the capsule identifying the
quarter for which the payment is made. Darken only
one capsule.
Box 4—Name and address. Enter your name and
address as shown on Form 941-SS.
Delete
● Enclose your check or money order payable to the
“United States Treasury.” Be sure also to enter your
EIN, “Form 941-SS,” and the tax period on your check
or money order. Do not send cash. Do not staple Form
941-V(SS) or your payment to Form 941-SS (or to each
other).
● Detach Form 941-V(SS) and send it with your
payment and Form 941-SS to the address in the
Instructions for Form 941-SS.
d

✃

Complete Form 941-V(SS), Payment Voucher, if you
are making a payment with Form 941-SS, Employer’s
QUARTERLY Federal Tax Return. We will use the
completed voucher to credit your payment more
promptly and accurately, and to improve our service to
you.
If you have your return prepared by a third party and
make a payment with that return, please provide this
payment voucher to the return preparer.

©

2

Dollars

3

4 Enter your business name (individual name if sole proprietor).

Enter the amount of your payment.

Tax period

2008

Do not staple this voucher or your payment to Form 941-SS.

1 Enter your employer identification
number (EIN).

1st
Quarter

3rd
Quarter

Enter your address.

2nd
Quarter

4th
Quarter

Enter your city, state, and ZIP code.

©

Cents

MAILOUT

8

I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 941-SS, PAGE 3 of 4 (Mailout)
MARGINS: TOP 13 mm (1⁄ 2 ") CENTER SIDES.
PRINTS: HEAD TO HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
FLAT SIZE: 216 mm (81⁄ 2 ") x 279 mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Layer 1 prints black

Form 941-V(SS),
Payment Voucher

Layer 3 prints 185 red

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Complete Form 941-V(SS), Payment Voucher, if you
are making a payment with Form 941-SS, Employer’s
QUARTERLY Federal Tax Return. We will use the
completed voucher to credit your payment more
promptly and accurately, and to improve our service to
you.
If you have your return prepared by a third party and
make a payment with that return, please provide this
payment voucher to the return preparer.

Making Payments With Form 941-SS

To avoid a penalty, make your payment with Form
941-SS only if:
● Your net taxes for the quarter (line 8 on Form
941-SS) are less than $2,500 and you are paying in full
with a timely filed return or
● You are a monthly schedule depositor making a
payment in accordance with the Accuracy of Deposits
Rule. See section 8 of Pub. 80 (Circular SS), Federal
Tax Guide for Employers in the U.S. Virgin Islands,
Guam, American Samoa, and the Commonwealth of
the Northern Mariana Islands, for details. In this case,
the amount of your payment may be $2,500 or more.
Otherwise, you must deposit your taxes at an
authorized financial institution or by using the
Electronic Federal Tax Payment System (EFTPS). See
section 8 of Circular SS for deposit instructions. Do
not use Form 941-V(SS) to make federal tax deposits.

✁

Ä

©

Specific Instructions

● Enter on the voucher the amount paid with Form Delete
941-SS.
● Enclose your check or money order made payable to
the “United States Treasury.” Be sure also to enter
your EIN, “Form 941-SS,” and the tax period on your
check or money order. Do not send cash. Do not
staple Form 941-V(SS) or your payment to Form
941-SS (or to each other).
● Detach Form 941-V(SS) and send it with your
payment and Form 941-SS to the address in the
d
Instructions for Form 941-SS. Do not send a
photocopy of Form 941-V(SS) because your payment
may be misapplied or delayed.
If any of the preprinted information is incorrect, make
changes on the top of Form 941-SS, not on the
payment voucher. If you change any of the preprinted
information on the voucher, your payment may be
misapplied or delayed.

payment

Detach Here and Mail With Your Payment and Form 941-SS. Ä

Department of the Treasury
Internal Revenue Service
d

Caution. Use Form 941-V(SS) when making any
payment with Form 941-SS. However, if you pay an
amount with Form 941-SS that should have been
deposited, you may be subject to a penalty. See
Deposit Penalties in section 8 of Pub. 80 (Circular SS).

✃

Purpose of Form

OMB No. 1545-0029

2008

Form 941-V(SS), Payment Voucher

Do not staple this voucher or your payment to your return.

Enter the amount of
your payment

Form 941-SS.

Dollars
©

Cents

(OTC and Mailout)

7

I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 941-SS, PAGE 4 of 4 (OTC and Mailout)
MARGINS: TOP 13 mm (1⁄ 2 ") CENTER SIDES.
PRINTS: HEAD TO HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
FLAT SIZE: 216 mm (81⁄ 2 ") x 279 mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

identification
Form 941-SS (Rev. 10-2008)

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Privacy Act and Paperwork Reduction Act Notice.
We ask for the information on this form to carry out the
Internal Revenue laws of the United States. We need it
to figure and collect the right amount of tax. Subtitle C,
Employment Taxes, of the Internal Revenue Code
imposes employment taxes on wages. This form is
used to determine the amount of the taxes that you
owe. Section 6011 requires you to provide the
requested information if the tax is applicable to you.
Section 6109 requires filers and paid preparers to
provide their identifying numbers. If you fail to provide
this information in a timely manner, you may be
subject to penalties and interest.
You are not required to provide the information
requested on a form that is subject to the Paperwork
Reduction Act unless the form displays a valid OMB
control number. Books and records relating to a form
or instructions must be retained as long as their
contents may become material in the administration of
any Internal Revenue law.

Generally, tax returns and return information are
confidential, as required by section 6103. However,
section 6103 allows or requires the IRS to disclose or
give the information shown on your tax return to others
as described in the Code. For example, we may
disclose your tax information to the Department of

Justice for civil and criminal litigation, and to cities,
states, the District of Columbia, and U.S.
commonwealths and possessions for use in
administering their tax laws. We may also disclose this
information to other countries under a tax treaty, to
federal and state agencies to enforce federal nontax
criminal laws, or to federal law enforcement
and show
Our records
intelligence agencies to combat terrorism.
this time, can you
The time needed to complete and
file this form will
update?
vary depending on individual circumstances. The
estimated average time is:
Recordkeeping
Learning about the law or the form
Preparing the form
Copying, assembling, and sending
the form to the IRS

86 hr., 27
7 min.
18 min.
24 min.
0 min.

If you have comments concerning the accuracy of
these time estimates or suggestions for making Form
941-SS simpler, we would be happy to hear from you.
You can write to: Internal Revenue Service, Tax
Products Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW,
IR-6526, Washington, DC 20224. Do not send Form
941-SS to this address. Instead, see Where Should
You File? on page 2 of the Instructions for Form
941-SS.

Printed on recycled paper