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

941-X:

Form
(Rev. June 2009)

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

(EIN)
Employer identification number

OMB No. 1545-0029

Return You Are Correcting ...

—

Check the type of return you are correcting:
941

Name (not your trade name)

941-SS

Trade name (if any)

Check the ONE quarter you are correcting:
Address
Number

Street

1: January, February, March

Suite or room number

2: April, May, June
City

State

ZIP code

3: July, August, September

Use this form to correct errors you made on Form 941 or 941-SS for one quarter only.
Type or print within the boxes. You MUST complete all three pages. Read the
instructions before completing this form. Do not attach this form to Form 941 or 941-SS.

4: October, November, December
Enter the calendar year of the quarter
you are correcting:

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 18, 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. 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 18. Do not
check this box if you are correcting ANY underreported amounts on this form.

(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 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 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 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 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 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. 6-2009)

Name (not your trade name)

Employer identification number (EIN)

Correcting quarter

(1, 2, 3, 4)

Correcting calendar year (YYYY)

Part 3: Enter the corrections for this quarter. If any line does not apply, leave it blank.
Column 1

Column 2

Total corrected
amount (for ALL
employees)

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

6. Wages, tips and other
compensation (from line 2 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)

.

7. Income tax withheld from
wages, tips, and other
compensation (from line 3 of
Form 941)

Column 3

=

=

=

=

Column 4

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

Tax correction

.

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

.

Copy Column
3 here ©

.

3 .124* =

.

.

*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.

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)

.

—

.

=

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

.

—

.

—

.

=

.

3 .029* =

.

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

.

Copy Column
3 here ©

.

=

.

See
instructions

.

=

.

See
instructions

.

.

See
instructions

.

=

.

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

.

—

.

=

.

17a. COBRA premium assistance
payments (from line 12a of Form
941 or 941-SS)

.

—

.

=

.

17b. Number of individuals provided
COBRA premium assistance
(from line 12b of Form 941 or
941-SS)

—

See
instructions

.

See
instructions

.

=

.

18. Total. Combine the amounts in lines 15, 16, and 17a of Column 4
If line 18 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 or abated.

If line 18 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 Amount You Owe in the instructions.
Next ©
Page

2

Form

941-X

(Rev. 6-2009)

Name (not your trade name)

Employer identification number (EIN)

Correcting quarter

(1, 2, 3, 4)

Correcting calendar year (YYYY)

Part 4: Explain your corrections for this quarter.
19.

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 21.

20.

Check here if any corrections involve reclassified workers. Explain on line 21.

21.

You must give us a detailed explanation of how you determined your corrections. See the instructions.

Part 5: Sign here. You must complete all three pages of this form 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, including
accompanying schedules and statements, 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

(Rev. 6-2009)

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.

BOTH
underreported
and
overreported
amounts

● Check the box on line 1.
● Pay the amount you owe from line 18 when you file Form 941-X.

The process you
use depends on
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
or Form 941-SS expires ...

Choose either process to correct the
overreported amounts.
Choose the adjustment process if you want the
amount shown on line 18 credited to your Form
941, Form 941-SS, Form 944, or Form 944-SS for
the period in which you file Form 941-X. Check the
box on line 1.
OR
Choose the claim process if you want the
amount shown on line 18 refunded to you or
abated. 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 or Form 941-SS ...

You must use the claim 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
or Form 941-SS expires ...

Choose either the adjustment process or both
the adjustment process and the claim process
when you correct both underreported and
overreported amounts.
Choose the adjustment process if combining
your underreported amounts and overreported
amounts results in a balance due or creates a
credit that you want applied to Form 941, Form
941-SS, Form 944, or Form 944-SS.
● File one Form 941-X, and
● Check the box on line 1 and follow the
instructions on line 18.
OR
Choose both the adjustment process and the
claim process if you want the overreported
amount refunded to you or abated.
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 18 when you file Form 941-X.
2. For the claim 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 or Form
941-SS ...

You must use both the adjustment process and
claim 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 18 when you file Form 941-X.
2. For the claim process, file a second Form
941-X to correct the overreported amounts.
Check the box on line 2.
Form

941-X

(Rev. 6-2009)