Form Schedule D (Form 9 Schedule D (Form 9 Report for Discrepancies Caused by Acquisitions, Statuto

Schedule D (Form 941):

Report of Discrepancies Caused by Acquisitions, Statutory Mergers, or Consolidations
(Rev. June 2011)

Department of the Treasury—Internal Revenue Service

OMB No. 1545-0029

—

Employer Identification Number (EIN)

Tax Year of Discrepancies (Fill in)
Format: YYYY

Name (not your trade name)
Trade name (if any)

Type of Submission (Check one)

Address
Number

Street

Suite or room number

Original
City

State

ZIP code

Corrected

Phone number

About this schedule
Each year the Internal Revenue Service (IRS) and the Social Security Administration (SSA) compare the totals on your Forms 941,
Employer’s QUARTERLY Federal Tax Return, with the totals on Forms W-2, Wage and Tax Statement, to verify that:
• The wages you reported on Forms 941 match those you reported on Forms W-2 (Copy A) so that your
employees’ social security earnings records are complete for benefit purposes; and
• You have paid the appropriate taxes.
Generally, the totals on your Forms W-2 (Copy A) should equal the totals you reported on Forms 941. Use this schedule if discrepancies
exist between the totals you reported on those forms ONLY as a result of an acquisition, statutory merger, or consolidation. In many cases,
the information on this schedule should help the IRS resolve discrepancies without contacting you. If you are an eligible employer
who elects to use the alternate procedure set forth in Rev. Proc. 2004-53, explained in the instructions, you should file this schedule.
Read the separate instructions before you fill out this schedule.
Part 1: Answer these background questions.
1. Are you filing this schedule —
After a statutory merger or consolidation? (See Rev. Rul. 62-60, 1962-1 C.B. 186 and Rev. Proc. 2004-53, 2004-2 C.B. 320.)
You are either:

An acquired corporation or
A surviving corporation.

OR

After an acquisition and you are using the alternate procedure under Rev. Proc. 2004-53, 2004-2 C.B. 320?
You are either:

A predecessor or
A successor.

2. The effective date of the statutory merger/consolidation or acquisition is

. . . . . . . . .
MM

3. The OTHER PARTY in this transaction is . . .

/

DD

/

YYYY

—

Other party’s EIN
Other party’s name
Trade name (if any)
Address
Number

Street

City

Suite or room number

State

Phone number
For Paperwork Reduction Act Notice, see separate instructions.

ZIP code

Next ■▶
Cat. No. 38791Y

Schedule D (Form 941) (Rev. 6-2011)

Your EIN

—

Tax Year of Discrepancies (Fill in)

Name (not your trade name)

Other party’s EIN

Format: YYYY

—

Part 2: Tell us about the discrepancies with your returns.
Column A
Amount you reported to IRS
for the tax year

Column B
– Amount you reported to SSA
for the tax year

Totals from Forms 941 as corrected
by any Forms 941-X

Column C
= The difference

Totals from Forms W-2 (Copy A) as
corrected by any Forms W-2c (Copy A)
–

=

5. Medicare wages and tips

–

=

6. Social security tips
7. Federal income tax
withheld

–

=

–

=

8. Advance earned income credit

–

=

4. Social security wages

(EIC) payments (for tax years
ending before January 1, 2011)

If you are filing for one transaction only, STOP here. If you are filing for more than one transaction, go to Part 3.

Part 3: Fill this part out ONLY if you are filing more than one Schedule D (Form 941) for any calendar year.

9. File one Schedule D (Form 941) for each separate transaction. This is schedule

Column A
Amount you reported to IRS
for the tax year for the
employees affected by the
transaction reported on this
Schedule D (Form 941)

of

. (Example: This is schedule 1 of 3.)

Column B
– Amount you reported to SSA
for the tax year for the
employees affected by the
transaction reported on this
Schedule D (Form 941)

Totals from Forms 941 as corrected
by any Forms 941-X

Column C
= The difference

Totals from Forms W-2 (Copy A) as
corrected by any Forms W-2c (Copy A)

10. Social security wages

–

=

11. Medicare wages and tips

–

=

12. Social security tips

–

=

13. Federal income tax
withheld

–

=

–

=

14. Advance earned income credit
(EIC) payments (for tax years
ending before January 1, 2011)

Page 2

Schedule D (Form 941) (Rev. 6-2011)