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

941-SS for 2013:

Employer’s QUARTERLY Federal Tax Return

Form
(Rev. January 2013)
Department of the Treasury — Internal Revenue Service

American Samoa, Guam, the Commonwealth of the Northern
Mariana Islands, and the U.S. Virgin Islands

Report for this Quarter of 2013

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Employer identification number (EIN)

OMB No. 1545-0029

(Check one.)

1: January, February, March

Name (not your trade name)

2: April, May, June
Trade name (if any)

3: July, August, September

Address

4: October, November, December
Number

Street

Suite or room number

Instructions and prior year forms are available
at www.irs.gov/form941ss.
City

ZIP code

State

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)

1

2
3
4

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

Column 2

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Check and go to line 6.

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5a

Taxable social security wages

5b

Taxable social security tips

5c

Taxable Medicare wages & tips

5d

Taxable wages & tips subject to
Additional Medicare Tax withholding

5e

Add Column 2 from lines 5a, 5b, 5c, and 5d .

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5e

5f

Section 3121(q) Notice and Demand—Tax due on unreported tips (see instructions) .

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5f

6

Total taxes before adjustments (add lines 5e and 5f) .

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6

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Current quarter’s adjustment for fractions of cents .

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7

8

Current quarter’s adjustment for sick pay .

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

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9

10

Total taxes after adjustments. Combine lines 6 through 9

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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 filed in the current quarter . . .

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12a

COBRA premium assistance payments (see instructions)

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12b

Number of individuals provided COBRA premium assistance .

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13

Add lines 11 and 12a .

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14
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× .124 =
× .124 =
× .029 =
× .009 =
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13

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

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14

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

Check one:

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Apply to next return.

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.

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Send a refund.

Next ■▶
Cat. No. 17016Y

Form 941-SS (Rev. 1-2013)

Employer identification number (EIN)

Name (not your trade name)

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 10 on this return is less than $2,500 or line 10 on the return for the prior quarter was less than $2,500,
and you did not incur a $100,000 next-day deposit obligation during the current quarter. If line 10 for the prior
quarter was less than $2,500 but line 10 on this return 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 (Form 941). 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:

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Month 1
Month 2
Month 3

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-SS.

Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank.
17

If your business has closed or you stopped paying wages .

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Check here, and

If you are a seasonal employer and you do not have to file a return for every quarter of the year

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Check here.

enter the final date you paid wages
18

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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 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

Print your
title here

Date

Best daytime phone

Paid Preparer Use Only

Check if you are self-employed .

Preparer’s name

PTIN

Preparer’s signature

Date

Firm’s name (or yours
if self-employed)

EIN

Address

Phone

City
Page 2

State

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ZIP code
Form 941-SS (Rev. 1-2013)

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

Specific Instructions

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.

Box 1—Employer identification number (EIN). If you
do not have an EIN, you may apply for one online. Go to
IRS.gov and click on the Apply for an EIN Online link
under "Tools." You may also apply for an EIN by calling
1-800-829-4933, or you can fax or mail Form SS-4,
Application for Employer Identification Number, to the
IRS. If you have not received your EIN by the due date of
Form 941-SS, 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.

To avoid a penalty, make your payment with Form
941-SS only if:
• Your total taxes after adjustments for either the current
quarter or the preceding quarter (Form 941-SS, line 10)
are less than $2,500, you did not incur a $100,000 nextday 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 make deposits by electronic funds
transfer. See section 8 of Pub. 80 (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).

Form

✁

▼

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

941-V(SS)

▼

Payment Voucher

Department of the Treasury
Internal Revenue Service
1 Enter your employer identification
number (EIN).

▶

2

4

1st
Quarter

3rd
Quarter

2nd
Quarter

4th
Quarter

2013
Dollars

Enter the amount of your payment. ▶

Tax period

OMB No. 1545-0029

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

Make your check or money order payable to “United States Treasury”
3

✃

Making Payments With Form 941-SS

Enter your business name (individual name if sole proprietor).
Enter your address.
Enter your city, state, and ZIP code.

Cents

Form 941-SS (Rev. 1-2013)

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 and provides
for income tax withholding. Form 941-SS 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 you to
provide your identification number. If you fail to provide
this information in a timely manner or provide false or
fraudulent information, you may be subject to penalties.
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 . . . . . . . . . 10 hrs., 31 min.
Learning about the law or the form . . . . 47 min.
Preparing, copying, assembling, and
sending the form to the IRS . . . . . . . . 1 hr.
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 email us at taxforms@irs.gov. Enter “Form
941-SS” on the subject line. Or write to: Internal Revenue
Service, Tax Products Coordinating Committee,
SE:W:CAR:MP:T:M:S, 1111 Constitution Ave. NW,
IR-6526, Washington, DC 20224. Do not send Form
941-SS to this address. Instead, see Where Should
You File? in the Instructions for Form 941-SS.