941-X Adjusted Employer's Quarterly Federal Tax Return or Clai

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Date

2
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 941-X, PAGE 1 of 4
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

941-X:

Date

Signature

O.K. to print

PRINTS: HEAD TO HEAD
INK: BLACK

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

Form
(January 2009)

Action

Revised proofs
requested

Adjusted Employer’s QUARTERLY Federal Tax Return or Claim for Refund
Department of the Treasury — Internal Revenue Service

Employer identification number
(EIN)

OMB No. 1545-0029

Return You Are Correcting ...

—

Check the type of return you are correcting:
941

Name (not your trade name)

941-SS
Address
Number

Street

Suite or room number

Check the quarter you are correcting:
1: January, February, March

City

State

ZIP code

2: April, May, June

Use this form to correct errors you made on Form 941, Employer’s QUARTERLY Federal
Tax Return, for one quarter only. Please type or print within the boxes. You MUST
complete all three pages. Read the instructions before you complete this form.

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Part 1: Select ONLY one process.

1. Adjusted employment tax return. Check this box if you underreported amounts. Also
check this box if you overreported amounts and you would like to use the adjustment
process to correct the errors. You must check this box if you are correcting both
underreported and overreported amounts on this form. The amount shown on line 17, if
less than 0, may only be applied as a credit to your Form 941, Form 941-SS, Form 944, or
Form 944-SS for the tax period in which you are filing this form.
2. Claim for refund of employment taxes. Check this box if you overreported amounts
only and you would like to use the claim process to ask for a refund or abatement of the
amount shown on line 17. Do not check this box if you are correcting ANY underreported
amounts on this form.

3: July, August, September
4: October, November, December
Enter the calendar year of the quarter
you are correcting:
(YYYY)

Enter the date you discovered errors:
/

/

(MM / DD / YYYY)

Part 2: Complete the certifications.

3. I certify that I have filed or will file Forms W-2, Wage and Tax Statement, or Forms W-2c, Corrected Wage and Tax Statement,
as required.

Note. If you are correcting underreported amounts only, go to Part 3 on page 2 and skip lines 4 and 5.
4. If you checked line 1 because you are adjusting overreported amounts, check all that apply. You must check at least one box.
I certify that:
a. I repaid or reimbursed each affected employee for the overcollected federal income tax for the current year and the overcollected
social security and Medicare tax for current and prior years. For adjustments of employee social security and Medicare tax
overcollected in prior years, I have a written statement from each employee stating that he or she has not claimed (or the claim
was rejected) and will not claim a refund or credit for the overcollection.
b. The adjustment of social security tax and Medicare tax is for the employer’s share only. I could not find the affected employees or
each employee did not give me a written statement that he or she has not claimed (or the claim was rejected) and will not claim a
refund or credit for the overcollection.
c. The adjustment is for federal income tax, social security tax, and Medicare tax that I did not withhold from employee wages.
5. If you checked line 2 because you are claiming a refund or abatement of overreported employment taxes, check all that apply.
You must check at least one box.
I certify that:
a. I repaid or reimbursed each affected employee for the overcollected social security and Medicare tax. For refund claims of
employee social security and Medicare tax overcollected in prior years, I have a written statement from each employee stating that
he or she has not claimed (or the claim was rejected) and will not claim a refund or credit for the overcollection.
b. I have a written consent from each affected employee stating that I may file this refund claim for the employee’s share of social
security and Medicare tax. For refunds of employee social security and Medicare tax overcollected in prior years, I also have a
written statement from each employee stating that he or she has not claimed (or the claim was rejected) and will not claim a refund
or credit for the overcollection.
c. The refund claim for social security tax and Medicare tax is for the employer’s share only. I could not find the affected employees;
or each employee did not give me a written consent to file a refund claim for the employee’s share of social security and Medicare
tax; or each employee did not give me a written statement that he or she has not claimed (or the claim was rejected) and will not
claim a refund or credit for the overcollection.
d. The refund claim is for federal income tax, social security tax, and Medicare tax that I did not withhold from employee wages.

Next ©
For Privacy Act and Paperwork Reduction Act Notice, see the instructions.

Cat. No. 17025J

Form

941-X

(Rev. 1-2009)

2
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 941-X, PAGE 2 of 4
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

Name (not your trade name)

Employer identification number (EIN)

Quarter

(1, 2, 3, 4)

Calendar Year (YYYY)

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Part 3: Enter the corrections for this quarter. If any line does not apply, leave it blank.
Column 2

Column 1

Total corrected
amount (for ALL
employees)

6. Wages,
tips
and
other
compensation (from line 2 of
Form 941)
7. Income tax withheld from
wages,
tips,
and
other
compensation (from line 3 of
Form 941)
8. Taxable social security wages
(from line 5a, Column 1 of
Form 941 or Form 941-SS)
9. Taxable social security tips
(from line 5b, Column 1 of
Form 941 or Form 941-SS)
10. Taxable Medicare wages and
tips (from line 5c, Column 1 of
Form 941 or Form 941-SS)
11. Tax adjustments
(from lines 7a through 7c of Form
941 or Form 941-SS)

Column 3

—

—

=

Use the amount in Column 1 when
you prepare your Forms W-2 or
Forms W-2c.

—

=

Copy Column
3 here ©

=

3 .124* =

—

Difference
(If this amount is a
negative number, use
a minus sign.)

Column 4

Amount originally reported
or as previously corrected
(for ALL employees) =

Tax correction

*If you are correcting your employer share only, use .062. See instructions.

—

=

3 .124* =

*If you are correcting your employer share only, use .062. See instructions.

—

=

3 .029* =

*If you are correcting your employer share only, use .0145. See instructions.

—

12. Special addition to wages for
federal income tax

—

13. Special addition to wages for
social security taxes

—

14. Special addition to wages for
Medicare taxes

—

=

Copy Column
3 here ©

=

See
instructions

=

See
instructions

=

See
instructions

=

See
instructions

15. Subtotal. Combine the amounts on lines 7–14 of Column 4
16. Advance earned income credit
(EIC) payments made to
employees (from line 9 of Form
941)

—

17. Total. Combine the amounts in lines 15 and 16 of Column 4
If line 17 is less than 0:
● If you checked line 1, this is the amount you want applied as a credit to your Form 941 or Form 941-SS for the tax period in
which you are filing this form. (If you are currently filing a Form 944 or Form 944-SS, Employer’s ANNUAL Federal Tax Return, see
the instructions.)
● If you checked line 2, this is the amount you want refunded.
If line 17 is more than 0, this is the amount you owe. Pay this amount when you file this return. For information on how to pay,
see the instructions.

Page

2

Form

941-X

(Rev. 1-2009)

2
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 941-X, PAGE 3 of 4
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

Name (not your trade name)

Employer identification number (EIN)

Quarter

(1, 2, 3, 4)

Calendar Year (YYYY)

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Part 4: Explain your corrections for this quarter.
18.

Check here if any corrections you entered on a line include both underreported and overreported amounts.
Explain both your underreported and overreported amounts on line 20.

19.

Check here if any corrections involve reclassified workers. Explain on line 20.

20.

You must give us a detailed explanation for how you determined your corrections (see instructions).

Part 5: Sign here. You must complete all three pages of Form 941-X and sign it.
Under penalties of perjury, I declare that I have filed an original Form 941 or Form 941-SS and that I have examined this adjusted return or claim for refund
and any schedules or statements that are attached, and to the best of my knowledge and belief, they are 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

3

–

Check if you are self-employed

Preparer’s name

City

)

State

/

(

/

)

–

ZIP code
Form

941-X

(1-2009)

2
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 941-X PAGE 4 of 4
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: 73⁄ 4 " FROM TOP (31⁄ 4 " FROM BOTTOM)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Type of errors
you are
correcting

Form 941-X: Which process should you use?

Underreported
amounts
ONLY

Use the adjustment process to correct underreported amounts.

Overreported
amounts
ONLY

The process you
use depends on
when you file
Form 941-X.

● Check the box on line 1.
● Pay the amount you owe from line 17 when you file Form 941-X.
If you are filing Form 941-X
MORE THAN 90 days before
the period of limitations on
credit or refund for Form
941 expires ...

Choose either process to correct the
overreported amounts.
Choose the adjustments process if you want
the amount shown on line 17 credited to your
Form 941-X for the period in which you file Form
941. Check the box on line 1.
OR
Choose the claim for refund process if you
want the amount shown on line 17 refunded to
you or abated. Check the box on line 2.

BOTH
underreported
and
overreported
amounts

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The process you
use depends on
when you file
Form 941-X.

If you are filing Form 941-X
WITHIN 90 days of the
expiration of the period of
limitations on credit or
refund for Form 941 ...

You must use the claim for refund process to
correct the overreported amounts. Check the
box on line 2.

If you are filing Form 941-X
MORE THAN 90 days before
the period of limitations on
credit or refund for Form
941 expires ...

Choose either the adjustment process or both
the adjustment process and the claim for refund
process when you correct both underreported
and overreported amounts.
Choose the adjustment process if you want to
offset your underreported amounts with your
overreported amounts.
● File one Form 941-X, and
● Check the box on line 1 and follow the
instructions on line 17.
OR

Choose both the adjustment process and
claim for refund process if you want the
overreported amount refunded to you.
File two separate forms.
1. For the adjustment process file one Form
941-X to correct the underreported amounts.
Check the box on line 1. Pay the amount you
owe from line 17 when you file Form 941-X.
2. For the claim for refund process file a
second Form 941-X to correct the overreported
amounts. Check the box on line 2.

If you are filing Form 941-X
WITHIN 90 days of the
expiration of the period of
limitations on credit or
refund for Form 941 ...

You must use both the adjustment process and
claim for refund process.
File two separate forms.
1. For the adjustment process file one Form
941-X to correct the underreported amounts.
Check the box on line 1. Pay the amount you
owe from line 17 when you file Form 941-X.
2. For the claim for refund process file a
second Form 941-X to correct the
overreported amounts. Check the box on line 2.

Page

4

Form

941-X

(Rev. 1-2009)