Form 941-V (OTC) 941-V (OTC) Payment Voucher

Version A, Cycle 13

Form 941-V,
Payment Voucher
Purpose of Form
Complete Form 941-V, Payment Voucher, if you are
making a payment with Form 941, 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
To avoid a penalty, make your payment with Form 941
only if:
• Your net taxes for either the current quarter or the
preceding quarter (line 10 on Form 941) are less than
$2,500, you did not incur a $100,000 next-day deposit
obligation during the current quarter, and you are paying
in full with a timely filed return or

Caution. Use Form 941-V when making any payment with
Form 941. However, if you pay an amount with Form 941
that should have been deposited, you may be subject to a
penalty. See Deposit Penalties in section 11 of Pub. 15
(Circular E).

Specific Instructions
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.
Box 3—Tax period. Darken the circle identifying the
quarter for which the payment is made. Darken only
one circle.
Box 4—Name and address. Enter your name and
address as shown on Form 941.
• Enclose your check or money order made payable to
the "United States Treasury." Be sure to enter your
EIN, "Form 941," and the tax period on your check or
money order. Do not send cash. Do not staple Form
941-V or your payment to Form 941 (or to each other).
• Detach Form 941-V and send it with your payment
and Form 941 to the address in the Instructions for
Form 941.
Note. You must also complete the entity information
above Part 1 on Form 941.

DRAFT AS OF
April 28, 2010

Form



d

Detach Here and Mail With Your Payment and Form 941.

941-V

Payment Voucher

Department of the Treasury
Internal Revenue Service

1

d

a Do

Enter your employer identification
number (EIN).

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

1st
Quarter

3rd
Quarter

2nd
Quarter

4th
Quarter

2010
Dollars

Enter the amount of your payment. a

3 Tax Period

OMB No. 1545-0029

not staple this voucher or your payment to Form 941.
2

Enter your address.

Enter your city, state, and ZIP code.



• You are a monthly schedule depositor making a
payment in accordance with the Accuracy of Deposits
Rule. See section 11 of Pub. 15 (Circular E), Employer's
Tax Guide, for details. In this case, the amount of your
payment may be $2,500 or more.
Otherwise, you must deposit your payment at an
authorized financial institution or by using the Electronic
Federal Tax Payment System (EFTPS). See section 11 of
Pub. 15 (Circular E) for deposit instructions. Do not use
Form 941-V to make federal tax deposits.

Cents