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

Tax Forms & Publications

Work Request Notification
Title: 1st Quarter 2011 Form 941, Employer's QUARTERLY Federal Tax Return
Tax Year: 2011

Processing Year: 2011

Route to:

Approved:

Section Chief:
Reviewer:
Review Chief:
Branch Chief:

Tuawana Pinkston

Michael Ecker
Johnny Cervantes (Michael Ecker, Acting)

Cynthia Ozkaya

Curt Freeman
Senior Technical Advisor: Bob
Erickson
Initiator (Tax Law Specialist): David

Date:

Tuawana Pinkston
Michael Ecker

Michael Ecker
cn=Michael Ecker, o=Internal
Revenue Service, ou=Tax Forms
and Publications, email=Michael.D.
Ecker@irs.gov, c=US
2007.09.19 13:59:41 -04'00'

Michael Ecker

Michael Ecker
cn=Michael Ecker, o=Internal
Revenue Service, ou=Tax Forms
and Publications, email=Michael.D.
Ecker@irs.gov, c=US
2007.09.19 13:59:41 -04'00'

Michael Ecker

Michael Ecker

Digitally signed by Tuawana Pinkston
DN: cn=Tuawana Pinkston, o=IRS, ou=SE:CAR:MP:
T:T:R, email=tuawana.pinkston@irs.gov, c=US
Date: 2010.09.09 14:34:04 -04'00'

09/09/10

Digitally signed by XGTGB
DN: cn=XGTGB, email=Michael.D.Ecker@irs.gov
Date: 2010.09.09 10:06:19 -04'00'

09/09/10

Digitally signed by XGTGB
DN: cn=XGTGB, email=Michael.D.Ecker@irs.gov
Date: 2010.09.10 08:34:34 -04'00'

09/10/10

Digitally signed by JCQFB
DN: cn=JCQFB, email=Cynthia.Ozkaya@irs.gov
Date: 2010.09.10 08:55:11 -04'00'

Curtis Freeman

DeCasseres David DeCasseres

09/10/10

2010.09.13 13:42:15
-04'00'

09/13/10

Digitally signed by David DeCasseres
DN: cn=David DeCasseres
Date: 2010.09.13 13:49:38 -04'00'

09/13/10

The information in this document can be used to develop any necessary Work Requests.
This notification is for changes due to:
✔ Legislation or Chief Counsel guidance: P.L. 111-147, section 101; P.L. 111-157, section 3; P.L. 111-226, section 219;
✔ A Program change initiated by: SB/SE Specialty Programs, Employment Tax Programs (Re: IRC section 3121(q))

The major changes are as follows:
This is the 3rd WRN for the 1st Quarter 2011 Form 941. This WRN replaces the two previous WRNs that were issued on October 28, 2009, and
May 6, 2010, respectively, because additional changes were implemented as a result of PL 111-226.
• The first WRN eliminated lines 12a, 12b, and 13, which were used for the COBRA premium credit. This credit has been
extended, therefore the lines will remain. This change was made in the second WRN. P.L. 111-157, section 3
• Currently SB/SE Employment Tax Exam advises employers to include on line 7c additional FICA and Medicare tax liability owed
as a result of an IRC section 3121(q) audit adjustment for unreported tips. Since this amount is a current liability and needs to
be transparent for reconciliation purposes, SB/SE Employment Tax Policy has requested a new line 5e to separately report the
liability. This item was entered in the 1st WRN.
• Lines 6a - 6d are NOT applicable under current law will remain on the form because the social security tax exemption may be extended
beyond December 31, 2010. However, if the exemption is not extended, the lines will be shaded. The text to the right of lines 5a - 5c and 6a 6c is subject to change. Also, the line references on line 6e are subject to change. Congress has proposed legislation extending the exemption
for wages paid before July 1, 2011. H.R. 6105, S. 3706
• Lines 12c -12e are removed because the employer social security tax exemption expires for wages paid after 12/31/2010.
This item was entered in the 2nd WRN. P.L. 111-147, section 201
• Lines 9 and 10 are removed due to the repeal of the advance earned income credit effective January 1, 2011. We renumbered lines 7a-7c as
7, 8, and 9, so subsequent lines can retain their original numbers. PL 111-226, section 219
• We clarified the instructions provided for the first checkbox (de minimis exception) on line 17. Regulations section 31.6302-1T(f)(4)

We may need to make further changes that would require a work request.
We do not anticipate the need for any further changes that would require a Work Request.
If you have any questions, please contact:
Name: David DeCasseres

Name: Michael Ecker

Title:

Title:

Tax Law Specialist

Tax Law Specialist (Reviewer)

Symbols: SE:W:CAR:MP:T:B:C

Symbols: SE:W:CAR:MP:T:B:R

Phone: 202-927-4268

Phone: 202-283-0196

Email: David.DeCasseres@irs.gov

Email: Michael.D.Ecker@irs.gov

Room: IR-6141

Room: NCFB C7-265

2011 /

January 2011 /

Version A, Cycle 12

941 for 2010:

Form
(Rev. April 2010)

Employer’s QUARTERLY Federal Tax Return

950111 /

951110
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

2011 /

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)

1

2

Wages, tips, and other compensation

3

Income tax withheld from wages, tips, and other compensation

4

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

1

.

.

.

.

Column 1

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.

.

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2

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3

Column 2

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.
.

5a

Taxable social security wages* .

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5b

Taxable social security tips* .

.

.

5c

Taxable Medicare wages & tips*

.

5d

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

× .124 =
× .124 =
× .029 =

.
.
Check and go to line 6e.
*At
the time
this form was
there
*Report
wages/tips
for printed,
this quarter,
was
no employer's
tax
including
thosesocial
paid security
to qualified
exemption
for wages on
paidlines
in 2011
to
new employees,
5a–5c.
qualified employees, as had applied in
Your liability for exempt wages/tips
2010. See the instructions for how to
reduced
onwas
lineextended.
6d (see
findwill
outbe
if this
provision

.
.
.

DRAFT AS OF
April 15, 2010
.

.

.

.

.

.

.

.

.

instructions).

.

5d

5e Section 3121(q) Notice and Demand - Tax due on unreported tips (see instructions) . . . . 5e "add entry box (same as line 5d)” /

Skip
6a - 6d, unless
the employer's
Seelines
instructions
for definitions
of
social“qualified
security taxemployees”
exemption forand
wages
paid to qualified employees was
“exempt wages/tips.”
extended.

6a

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

6b

Number of qualified employees paid exempt wages/tips this quarter

6c

Exempt wages/tips paid to qualified employees this quarter

6e

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

7

7a

Current quarter’s fractions of cents .

.

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8

7b

Current quarter’s sick pay

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9

7c

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

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.

10 8
delete

delete

.

.

.

.

× .062 =
.

6e

(add lines 3, 5d, and 5e; then subtract line 6d)

.

7a

.

.

.

7b

.

.

.

7c

.

.

.

.

8

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

.

9

.

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.

.

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.

9

Advance earned income credit (EIC) payments made to employees

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9

10

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

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10

11

Total deposits including prior quarter overpayments

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11

12a

COBRA premium assistance payments (see instructions)

.

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.

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

13

Add lines 11, 12a, and 12e

.

.

.

.

13

14

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

.

.

.

14

15

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

▶

.

.

.

. 11
. and
. .12a. / .

.

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

.
.

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.
.
.
.
.
.
.
.
.
.

6d

.

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.

× .062 =
.

.

.
.
.

12e

Check one:

Apply to next return.

Next ■▶

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)

1-2011 /

delete
text
and
box

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
Version A, Cycle 12
a $100,000 next-day deposit obligation during the current quarter. If you meet the de minimis exception based on the prior quarter and line
10 for the current quarter is $100,000 or more, you must provide a record of your federal tax liability. If you are a monthly schedule depositor,
complete the deposit schedule below; if you are a semiweekly schedule depositor, attach Schedule B. Go to Part 3.

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.

950211 /

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

"Remove bold"

DRAFT AS OF
April 15, 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

/

/

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.

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

.

.

delete
/

/

ZIP code
Form 941 (Rev. 4-2010)

1-2011 /