941-SS Employer's QUARTERLY Federal Tax Return: American Samoa,

Employer's Quarterly Federal Tax Return

2010 Form 944-SS

Form 941-SS - 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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I.R.S. SPECIFICATIONS

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

Signature

Revised proofs
requested

Reviewed by ME 05/10/10
Comments in green. Text Edits (deletions) in red.

Cumulative
Changes

941-SS for 2010:

Date

O.K. to print

PRINTS: HEAD TO HEAD
INK: BLACK

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

OK-to-Print As Corrected

Action

Employer’s QUARTERLY Federal Tax Return

Form
American Samoa, Guam, the Commonwealth of the Northern
(Rev. April 2010)
Mariana Islands, and the U.S. Virgin Islands
Department of the Treasury — Internal Revenue Service (77)
(EIN)
Employer identification number

—

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OMB No. 1545-0029

Report for this Quarter of 2010
(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. Type or print within the boxes.

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), or Dec. 12 (Quarter 4)

"x" should be lower
case for multiplication

2
3
4

5a Taxable social security wages*
s*

Column 1

5b Taxable social security tips*
s*
5c Taxable Medicare wages & tips*
s*

Column 2

.
.
.

.124 =

.124 =
.029 =

Check and go to line 6e.

endash

.
.
.

5d Add Column 2 line 5a, Column 2 line 5b, Column 2 line 5c
6a

6b Number of qualified employees paid exempt wages/tips this quarter

7b Current quarter’s adjustment for sick pay

x .062 =

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

Delete "12a" and "12b" expand boxes
right. See Form 941 for format.

10
11

endash

12a

12b Number of individuals provided COBRA premium assistance

12b

12c Number of qualified employees paid exempt wages/tips March 19-31

12c

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

12d Exempt wages/tips paid to qualified employees March 19-31
13

Add lines 11, 12a, and 12e

Balance due. If line 8 is more than line 13, enter difference and see instructions

x .062 =

.
.
.

12e
13

endash

Overpayment. If line 13 is more than line 8, enter difference

.
.

Total deposits, including prior quarter overpayments

12a COBRA premium assistance payments (see instructions)

.
.
.
.
.
.

Delete bold from highlighted text. 6e
Also, delete "s" from "lines" and
delete period at the end. A minus 7a
sign is longer than a hyphen.
7b

7c Current quarter’s adjustments for tips and group-term life insurance
8

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

6c Exempt wages/tips paid to qualified employees this quarter

7a Current quarter’s adjustment for fractions of cents

*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).

6a Number of qualified employees first paid exempt wages/tips this quarter

6e Total taxes before adjustments (lines 5d - line 6d = 6e.)

delete period

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

and

Changes
to 6a/b
should
help fix
font, which
is different
from other
lines.

Delete "6a" and "6b" expand boxes
right. See Form 941 for format.

14
Check one:

Apply to next return.

Send a refund.
Next

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

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

Cat. No. 17016Y

Form

941-SS

(Rev. 4-2010)

MAILOUT
I.R.S. SPECIFICATIONS

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

Make same changes
as noted on page 1.

See previous form
for changes

941-SS for 2010:

Employer’s QUARTERLY Federal Tax Return

Form
American Samoa, Guam, the Commonwealth of the Northern
(Rev. April 2010)
Mariana Islands, and the U.S. Virgin Islands
Department of the Treasury — Internal Revenue Service (77)

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OMB No. 1545-0029

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-SS. Type or print within the boxes.

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), or Dec. 12 (Quarter 4)

2
3
4

If no wages, tips, and other compensation are subject to social security or Medicare tax
Column 1

5a Taxable social security wages*
5b Taxable social security tips*
5c Taxable Medicare wages & tips*

.
.
.

Column 2

.124 =

.124 =
.029 =

Check and go to line 6e.

*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).

.
.
.

5d Add Column 2 line 5a, Column 2 line 5b, Column 2 line 5c
6a Number of qualified employees first paid exempt wages/tips this quarter

6b Number of qualified employees paid exempt wages/tips this quarter

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

6c Exempt wages/tips paid to qualified employees this quarter

x .062 =

.
.
.
.
.
.

6d
6e

6e Total taxes before adjustments (lines 5d - line 6d = 6e.)
7a Current quarter’s adjustment for fractions of cents

7b Current quarter’s adjustment for sick pay

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

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

9
10
11

12a COBRA premium assistance payments (see instructions)

12a

12b Number of individuals provided COBRA premium assistance

12b

12c Number of qualified employees paid exempt wages/tips March 19-31

12c

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

12d Exempt wages/tips paid to qualified employees March 19-31
13

Add lines 11, 12a, and 12e

Balance due. If line 8 is more than line 13, enter difference and see instructions

Overpayment. If line 13 is more than line 8, enter difference

.
.

Total deposits, including prior quarter overpayments

x .062 =

.
.
.

12e
13

14
Check one:

Apply to next return.

Send a refund.
Next

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

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

Cat. No. 17016Y

Form

941-SS

(Rev. 4-2010)

OTC & 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.

16
Check one:

Line 8 on this return is less than $2,500 or line 8 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

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.
18

If your business has closed or you stopped paying wages

Check here, and

/
/
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

–

Check if you are self-employed

Preparer’s name

City

)

(

)

–

ZIP code
Form

941-SS

(Rev. 4-2010)

OTC

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: 3.25" FROM BOTTOM
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

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Form 941-V(SS),
Payment Voucher
Purpose of Form

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 either the current quarter or the
preceding quarter (line 8 on Form 941-SS) 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 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 payment 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).

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-SS.
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-SS.
● Enclose your check or money order payable to the
“United States Treasury.” Be sure 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.
Note. You must also complete the entity information
above Part 1 on Form 941-SS.

Pub. 80 (Circular SS)

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

Department of the Treasury
Internal Revenue Service

1 Enter your employer identification
number (EIN).

OMB No. 1545-0029

Payment Voucher

Form

✃

✁
941-V(SS)

Dollars

Enter the amount of your payment.

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

Tax period

2010

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

1st
Quarter

3rd
Quarter

Enter your address.

2nd
Quarter

4th
Quarter

Enter your city, state, and ZIP code.

Cents

MAILOUT

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: 3.25" FROM BOTTOM
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Layer 1 prints black

Layer 3 prints 185 red

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Form 941-V(SS),
Payment Voucher
Purpose of Form

Making Payments With Form 941-SS

Specific Instructions

● Enter on the voucher the amount paid with Form
941-SS.
● Enclose your check or money order made payable to
the “United States Treasury.” Be sure 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. 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.

Pub. 80 (Circular SS)

✃

✁

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

Department of the Treasury
Internal Revenue Service

OMB No. 1545-0029

2010

Form 941-V(SS), Payment Voucher

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

Enter the amount of
your payment

Dollars

Cents

OTC & Mailout

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

Update burden
Form 941-SS (Rev. 4-2010)

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Privacy Act and Paperwork Reduction Act Notice.
We ask for the information on Form 941-SS 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
intelligence agencies to combat terrorism.
The time needed to complete and file Form 941-SS
will 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

XX hr., XX min.
XX min.
XX min.
XX 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

File Type	application/pdf
File Title	Form 941-SS (Rev. May 2010)
Subject	Employer's Quarterly Federal Tax Return (American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, and the U.S. Vi
Author	SE:W:CAR:MP
File Modified	2010-05-14
File Created	2010-05-14