Form Schedule B (Form 9 Schedule B (Form 9 Report of Tax Liability for Semiweekly Schedule Deposito

Schedule B (Form 941):

960311

Report of Tax Liability for Semiweekly Schedule Depositors
(Rev. June 2011)

OMB No. 1545-0029

Department of the Treasury — Internal Revenue Service

(EIN)
Employer identification number

Report for this Quarter...
(Check one.)

—

1: January, February, March
Name (not your trade name)

2: April, May, June

Calendar year

3: July, August, September

(Also check quarter)

4: October, November, December
Use this schedule to show your TAX LIABILITY for the quarter; DO NOT use it to show your deposits. When you file this form with Form 941 or
Form 941-SS, DO NOT change your tax liability by adjustments reported on any Forms 941-X. You must fill out this form and attach it to Form
941 or Form 941-SS if you are a semiweekly schedule depositor or became one because your accumulated tax liability on any day was
$100,000 or more. Write your daily tax liability on the numbered space that corresponds to the date wages were paid. See Section 11 in
Pub. 15 (Circular E), Employer’s Tax Guide, for details.
Month 1
1
2
3
4
5
6
7
8
Month 2
1
2
3
4
5
6
7
8
Month 3
1
2
3
4
5
6
7
8

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9
10
11
12
13
14
15
16

9
10
11
12
13
14
15
16

9
10
11
12
13
14
15
16

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17
18
19
20
21
22
23
24

17
18
19
20
21
22
23
24

17
18
19
20
21
22
23
24

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25
26
27
28
29
30
31

25
26
27
28
29
30
31

25
26
27
28
29
30
31

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Tax liability for Month 1

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Tax liability for Month 2

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Tax liability for Month 3

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Total liability for the quarter

Fill in your total liability for the quarter (Month 1 + Month 2 + Month 3)

▶

Total must equal line 10 on Form 941 or Form 941-SS.

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 11967Q

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