Form 941 Form 941 Employee's Quarterly Federal Tax Return

Employer's Quarterly Federal Tax Return

2010 Form 941

Forms 941, Employer's Quarterly Federal Tax Return; American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, and the U.S. Virgin Islands

OMB: 1545-0029

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Reviewed by ME 5/7/2010
Comments in blue.

941 for 2010:

Form
(Rev.. April 2010)

Version A, Cycle 13

951110
511

Employer’s QUARTERLY Federal Tax Return

OMB No. 1545-0029

Department of the Treasury — Internal Revenue Service

(EIN)

—

Report for this Quarter of 2010

Employer identification number

(Check one.)

Name (not your trade name)

1: January, February, March
2: April, May, June

Trade name (if any)

3: July, August, September

Address
Number

Street

Suite or room number

City

State

4: October, November, December

ZIP code

Read the separate instructions before you complete Form 941. Type or print within the boxes.

Part 1: Answer these questions for this quarter.
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), or Dec. 12 (Quarter 4)

Wages, tips, and other compensation

Income tax withheld from wages, tips, and other compensation

If no wages, tips, and other compensation are subject to social security or Medicare tax

Column 1

Check and go to line 6e.

Column 2

.
.
.

*Report wages/tips for this quarter,
including those paid to qualified
new employees, on lines 5a–5c.
Your liability for exempt wages/tips
will be reduced on line 6d (see
instructions).

.
.
.

× .124 =

s* .
Taxable social security wages*

s* .
Taxable social security tips*

Taxable Medicare wages & tips*

Add Column 2 line 5a, Column 2 line 5b, and Column 2 line 5c

Number of qualified employees first paid exempt wages/tips this quarter

Number of qualified employees paid exempt wages/tips this quarter

Exempt wages/tips paid to qualified employees this quarter

Total taxes before adjustments (line 3 + line 5d – line 6d = line 6e) .

Current quarter’s adjustment for fractions of cents .

Current quarter’s adjustment for sick pay .

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

Total taxes after adjustments. Combine lines 6e through 7c .

Advance earned income credit (EIC) payments made to employees

Total taxes after adjustment for advance EIC (line 8 – line 9 = line 10)

× .124 =
× .029 =

.
.

DRAFT AS OF
April 28, 2010
.

See instructions for definitions of
“qualified employees” and
“exempt wages/tips.”

× .062 =

.
.
.
.
.
.
.
.
.
.

d
.

Insert comma
.

12a

12b

Number of individuals provided COBRA premium assistance .

12c

Number of qualified employees paid exempt wages/tips March 19–31

12d

Exempt wages/tips paid to qualified employees March 19–31

Add lines 11, 12a, and 12e

Balance due. If line 10 is more than line 13, enter the difference and see instructions

Overpayment. If line 13 is more than line 10, enter the difference

Total deposits including prior quarter overpayments

12a

COBRA premium assistance payments (see instructions)

Complete lines 12c, 12d, and 12e
only for the 2nd quarter of 2010.

.
.

× .062 =
.

.
.
.

12e

Check one:

Apply to next return.

Next Na

You MUST complete both pages of Form 941 and SIGN it.

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

Send a refund.

Cat. No. 17001Z

Form 941 (Rev. 4-2010)
4-

Version A, Cycle 13

The same changes made to the above OTC page 1
were made to this page (the mail-out a page 1).

941 for 2010:

Form
(Rev. April 2010)

961110

Employer’s QUARTERLY Federal Tax Return

OMB No. 1545-0029

Department of the Treasury — Internal Revenue Service

Report for this Quarter of 2010
(Check one.)

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

Read the separate instructions before you complete Form 941. Type or print within the boxes.

Wages, tips, and other compensation

Income tax withheld from wages, tips, and other compensation

If no wages, tips, and other compensation are subject to social security or Medicare tax

Column 1

Check and go to line 6e.

Column 2

.
.
.

Taxable social security wages* .

Taxable social security tips* .

Taxable Medicare wages & tips*

Add Column 2 line 5a, Column 2 line 5b, and Column 2 line 5c

Number of qualified employees first paid exempt wages/tips this quarter

Number of qualified employees paid exempt wages/tips this quarter

Exempt wages/tips paid to qualified employees this quarter

Total taxes before adjustments (line 3 + line 5d – line 6d = line 6e)

Current quarter’s adjustment for fractions of cents .

Current quarter’s adjustment for sick pay .

*Report wages/tips for this quarter,
including those paid to qualified
new employees, on lines 5a–5c.
Your liability for exempt wages/tips
will be reduced on line 6d (see
instructions).

.
.
.

× .124 =

× .124 =
× .029 =

DRAFT AS OF
April 28, 2010
.

See instructions for definitions of
“qualified employees” and
“exempt wages/tips.”

× .062 =

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

Total taxes after adjustments. Combine line 6e through 7c .

Advance earned income credit (EIC) payments made to employees

Total taxes after adjustment for advance EIC (line 8 – line 9 = line 10)

Insert comma
. . . . . . . . . . . .

Total deposits including prior quarter overpayments

12a

COBRA premium assistance payments (see instructions)

12b

Number of individuals provided COBRA premium assistance .

12c

Number of qualified employees paid exempt wages/tips March 19–31

12d

Exempt wages/tips paid to qualified employees March 19–31

Add lines 11, 12a, and 12e

12a

Complete lines 12c, 12d, and 12e
only for the 2nd quarter of 2010.

× .062 =

12e

Balance due. If line 10 is more than line 13, enter the difference and see instructions

Overpayment. If line 13 is more than line 10, enter the difference

.
.
.
.
.
.
.
.
.
.

.
.

Check one:

.
.
.
Apply to next return.

Next Na

You MUST complete both pages of Form 941 and SIGN it.

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

Send a refund.

Cat. No. 17001Z

Form 941 (Rev. 4-2010)

Version A, Cycle 13

950210
Name (not your trade name)

Employer identification number (EIN)

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. 15
(Circular E), section 11.
Write the state abbreviation for the state where you made your deposits OR write “MU” if you made your
deposits in multiple states.

16
17 Check one:

Line 10 on this return is less than $2,500 or line 10 on the return for the preceding quarter was less than $2,500, and you
did not incur a $100,000 next-day deposit obligation during the current quarter. Go to Part 3.

You were a monthly schedule depositor for the entire quarter. Enter your tax liability
for each month and total liability for the quarter, then go to Part 3.
Tax liability:

.
.
.
.

Month 1
Month 2
Month 3

DRAFT AS OF
April 28, 2010

Total liability for quarter

Total must equal line 10.

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.

Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank.
18 If your business has closed or you stopped paying wages .

Check here, and

19 If you are a seasonal employer and you do not have to file a return for every quarter of the year

Check here.

enter the final date you paid wages

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 the IRS.
No.

Part 5: Sign here. You MUST complete both pages of Form 941 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

Check if you are self-employed .

Preparer’s name

Preparer’s
SSN/PTIN

Preparer’s signature

Date

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

EIN

Address

Phone

City
Page 2

State

ZIP code
Form 941 (Rev. 4-2010)
4-

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.

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

Detach Here and Mail With Your Payment and Form 941.

941-V

Payment Voucher

Department of the Treasury
Internal Revenue Service

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

Version A, Cycle 13

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
• 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.

Specific Instructions
• Enter on the voucher the amount paid with
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. Do not send a photocopy of Form 941-V because
your payment may be misapplied or delayed.
If any of the preprinted information is incorrect, make
changes on the top of Form 941, not on the payment
voucher. If you change any of the preprinted
information on the voucher, your payment may be
misapplied or delayed.

DRAFT AS OF
April 28, 2010

Detach Here and Mail With Your Payment and Form 941.

Department of the Treasury
Internal Revenue Service
a Do

OMB No. 1545-0029

2010

not staple this voucher or your payment to Form 941.

Form 941-V, Payment Voucher
Enter the amount of
your payment . .

Dollars

Cents

Version A, Cycle 13

Form 941 (Rev. 4-2010)
4-

Privacy Act and Paperwork Reduction Act Notice.
We ask for the information on Form 941 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, including income
tax withholding. Form 941 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
its 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 intelligence agencies to combat
terrorism.
The time needed to complete and file Form 941 will
vary depending on individual circumstances. The
estimated average time is:
Recordkeeping . . . . . . . . . . 12 hr., 39 min.
Learning about the law or the form . . . . 40 min.
Preparing the form . . . . . . . . . 1 hr., 49 min.
Copying, assembling, and sending
the form to the IRS . . . . . . . . . . . 16 min.
If you have comments concerning the accuracy of
these time estimates or suggestions for making Form 941
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 to this address. Instead, see
Where Should You File? on page 4 of the Instructions for
Form 941.

DRAFT AS OF
April 28, 2010

File Type	application/pdf
File Title	Form 941 (Rev. May 2010)
Subject	Employer's Quarterly Federal Tax Return
Author	SE:W:CAR:MP
File Modified	2010-05-14
File Created	2010-05-14