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

Tax Forms & Publications

Work Request Notification
Title: Form 941-SS Employer's QUARTERLY Federal Tax Return (American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, and U.S. Virgin Islands)
Tax Year: 2011

Processing Year: 2011

Route to:

Approved:

Tuawana Pinkston

Section Chief:

Ron Gamble

Reviewer:
Review Chief:
Branch Chief:

Johnny Cervantes
Rene Mondesir

Senior Technical Advisor: Curtis Freeman
Initiator (Tax Law Specialist): Yvette

Date:

Tuawana Pinkston

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: 2010.01.20 09:31:51 -05'00'

01/20/10

Ronald W. Gamble

Digitally signed by Ronald W. Gamble
DN: cn=Ronald W. Gamble, o=Business Review, ou=SE:W:
CAR:MP:T:B:R, email=Ronald.W.Gamble@irs.gov, c=US
Date: 2010.01.21 14:40:39 -05'00'

01/21/10

Johnny Cervantes

Digitally signed by Johnny Cervantes
DN: cn=Johnny Cervantes, o=Internal Revenue Service, ou=SE:W:
CAR:MP:T:B:R, email=Johnny.Cervantes@irs.gov, c=US
Reason: I am approving this document
Date: 2010.02.01 16:47:37 -05'00'

02/01/10

Johnny Cervantes

Digitally signed by Johnny Cervantes
DN: cn=Johnny Cervantes, o=Internal Revenue Service, ou=SE:W:
CAR:MP:T:B:R, email=Johnny.Cervantes@irs.gov, c=US
Reason: I am approving this document
Date: 2010.02.01 16:47:45 -05'00'

02/01/10

2010.02.01 16:58:27
-05'00'

02/01/10

Digitally signed by C4JCB
DN: cn=C4JCB, email=Yvette.B.Lawrence@irs.
gov
Date: 2010.02.02 08:39:22 -05'00'

02/02/10

Curtis Freeman

Lawrence Yvette Lawrence

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. 111-5, section 3001
✔ A Program change initiated by: SB/SE Specialty Programs, Employment Tax Programs (Re: IRC section 3121(q))

The major changes are as follows:
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.
We changed "Preparer's SSN/PTIN" to "Preparer's PTIN". We expect regulations to become final to implement the new preparer
rules starting with 2011.

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: Yvette Lawrence

Name: Ron Gamble

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: 202-622-3776

Phone: 202-622-3841

Email: Yvette.B.Lawrence@irs.gov

Email: Ronald.W.Gamble@irs.gov

Room: IR-6141

Room: IR-6135

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I.R.S. SPECIFICATIONS

1

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

PRINTS: HEAD TO HEAD
INK: BLACK

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

Action

Date

Signature

O.K. to print
Revised proofs
requested

11

941-SS for 2010:

Employer’s QUARTERLY Federal Tax Return

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

—

OMB No. 1545-0029

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Report for this Quarter of 2010

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(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

2

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), Dec. 12 (Quarter 4)

5e. Section 3121 (q) amount (see instructions)..........................................................................................5e "insert entry box

3
4
5

1

If no wages, tips, and other compensation are subject to social security or Medicare tax
Taxable social security and Medicare wages and tips:
Column 1
Column 2
3 .124 =
5a Taxable social security wages
3 .124 =
5b Taxable social security tips
3 .029 =
5c Taxable Medicare wages & tips

.
.

Check and go to line 7.

.
.

.

Add Column 2 line 5a, Column 2 line 5b, and Column 2 line 5c
5d Total social security and Medicare taxes (Column 2, lines 5a + 5b + 5c = line 5d)

6
7

5d

Total taxes before adjustments. Add lines 5d and 5e..............................................................................6 "insert entry box (same as above)
CURRENT QUARTER’S ADJUSTMENTS, for example, a fractions of cents adjustment.
See the instructions.
7a Current quarter’s fractions of cents
7b Current quarter’s sick pay
7c Current quarter’s adjustments for tips and group-term life insurance

.
.
.

7d TOTAL ADJUSTMENTS. Combine all amounts on lines 7a through 7c

.
.

7d

6
8

Total taxes after adjustments. Combine lines 5d and 7d

8

9
10
11

Total deposits for this quarter, including overpayment applied from a
prior quarter and overpayment applied from Form 941-X or
Form 944-X

12a COBRA premium assistance payments (see instructions)
12b Number of individuals provided COBRA premium
assistance reported on line 12a

.
.

13

Add lines 11 and 12a

13

14

Balance due. If line 8 is more than line 13, write the difference here
For information on how to pay, see the instructions.
Overpayment. If line 13 is more than line 8, write the difference here

14

15

©

.

.
.
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. 1-2010)

11 /

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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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0

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
17

Check one:

Line 8 is less than $2,500. Go to Part 3.
You were a monthly schedule depositor for the entire quarter. Enter your tax liability
for each month. 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

19

/
/
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

2

–

Check if you are self-employed

Preparer’s name

City

)

/

(

/

)

–

ZIP code
Form

941-SS

(Rev. 1-2010)

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