Form 941-X - Adjusted Employer's Quarterly Federal Tax Return or Claim for Refund

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941-X:

Form
(Rev. April 2014)

Adjusted Employer's QUARTERLY Federal Tax Return or Claim for Refund
Department of the Treasury — Internal Revenue Service

Employer identification number
(EIN)

OMB No. 1545-0029

Return You Are Correcting ...

—

Check the type of return you are correcting:

941

Name (not your trade name)

DRAFT AS OF
October 29, 2013
DO NOT FILE
941-SS

Trade name (if any)

Check the ONE quarter you are correcting:

Address

Number

Street

1: January, February, March

Suite or room number

2: April, May, June

City

ZIP code

State

3: July, August, September

4: October, November, December

Foreign country name

Foreign province/county

Foreign postal code

Read the instructions before completing this form. Use this form to correct errors you
made on Form 941 or 941-SS. Use a separate Form 941-X for each quarter that needs
correction. Type or print within the boxes. You MUST complete all three pages. Do not
attach this form to Form 941 or 941-SS.
Part 1: Select ONLY one process. See page 4 for additional guidance.
1.

2.

Adjusted employment tax return. Check this box if you underreported amounts. Also
check this box if you overreported amounts and you would like to use the adjustment
process to correct the errors. You must check this box if you are correcting both
underreported and overreported amounts on this form. The amount shown on line 19, if
less than zero, may only be applied as a credit to your Form 941, Form 941-SS, or
Form 944 for the tax period in which you are filing this form.

Enter the calendar year of the
quarter you are correcting:
(YYYY)

Enter the date you discovered errors:

/
/
(MM / DD / YYYY)

Claim. Check this box if you overreported amounts only and you would like to use the
claim process to ask for a refund or abatement of the amount shown on line 19. Do not
check this box if you are correcting ANY underreported amounts on this form.

Part 2: Complete the certifications.
3.

I certify that I have filed or will file Forms W-2, Wage and Tax Statement, or Forms W-2c, Corrected Wage and Tax Statement,
as required.

Note. If you are correcting underreported amounts only, go to Part 3 on page 2 and skip lines 4 and 5.
4. If you checked line 1 because you are adjusting overreported amounts, check all that apply. You must check at least one box.
I certify that:
a.

I repaid or reimbursed each affected employee for the overcollected federal income tax or Additional Medicare Tax for the current
year and the overcollected social security and Medicare taxes for current and prior years. For adjustments of employee social
security and Medicare taxes overcollected in prior years, I have a written statement from each employee stating that he or she has
not claimed (or the claim was rejected) and will not claim a refund or credit for the overcollection.

b.

The adjustments of social security tax and Medicare tax are for the employer’s share only. I could not find the affected employees
or each employee did not give me a written statement that he or she has not claimed (or the claim was rejected) and will not claim
a refund or credit for the overcollection.

c.

The adjustment is for federal income tax, social security tax, Medicare tax, or Additional Medicare Tax that I did not withhold from
employee wages.

5. If you checked line 2 because you are claiming a refund or abatement of overreported employment taxes, check all that apply.
You must check at least one box.
I certify that:
a.

I repaid or reimbursed each affected employee for the overcollected social security and Medicare tax. For claims of employee
social security and Medicare tax overcollected in prior years, I have a written statement from each employee stating that he or she
has not claimed (or the claim was rejected) and will not claim a refund or credit for the overcollection.

b.

I have a written consent from each affected employee stating that I may file this claim for the employee’s share of social security
and Medicare tax. For refunds of employee social security and Medicare tax overcollected in prior years, I also have a written
statement from each employee stating that he or she has not claimed (or the claim was rejected) and will not claim a refund or
credit for the overcollection.

c.

The claim for social security tax and Medicare taxes is for the employer’s share only. I could not find the affected employees; or
each employee did not give me a written consent to file a claim for the employee’s share of social security and Medicare taxes; or
each employee did not give me a written statement that he or she has not claimed (or the claim was rejected) and will not claim a
refund or credit for the overcollection.

d.

The claim is for federal income tax, social security tax, Medicare tax, or Additional Medicare Tax that I did not withhold from
employee wages.
Next ■▶

For Paperwork Reduction Act Notice, see the instructions.

IRS.gov/form941x

Cat. No. 17025J

Form 941-X (Rev. 4-2014)

Employer identification number (EIN)

Name (not your trade name)

Correcting quarter

(1, 2, 3, 4)

Correcting calendar year (YYYY)

Part 3: Enter the corrections for this quarter. If any line does not apply, leave it blank.
Column 2

Column 1
Total corrected
amount (for ALL
employees)

—

Column 3

Amount originally
reported or as
previously corrected
(for ALL employees)

Column 4

Difference
(If this amount is a
negative number,
use a minus sign.)

Tax correction

DRAFT AS OF
October 29, 2013
DO NOT FILE
=

6.

Wages, tips and other
compensation (Form 941, line 2)

.

—

.

=

.

Use the amount in Column 1 when you
prepare your Forms W-2 or Forms W-2c.

7.

Federal income tax withheld
from wages, tips, and other
compensation (Form 941, line 3)

.

—

.

=

.

Copy Column
3 here ▶

.

8.

Taxable social security wages
(Form 941 or 941-SS, line 5a,
Column 1)

.

—

.

=

.

× .124* =

.

9.

*If you are correcting a 2011 or 2012 return, use .104. If you are correcting your employer share only, use .062. See instructions.

Taxable social security tips (Form
941 or 941-SS, line 5b, Column 1)

—

.

=

.

.

× .124* =

.

*If you are correcting a 2011 or 2012 return, use .104. If you are correcting your employer share only, use .062. See instructions.

10.

Taxable Medicare wages and tips
(Form 941 or 941-SS, line 5c, Column 1)

—

.

=

.

.

× .029* =

.

*If you are correcting your employer share only, use .0145. See instructions.

11.

12.

13.

Taxable wages & tips subject to
Additional Medicare Tax withholding
(Form 941 or 941-SS, line 5d; only for
quarters beginning after December 31, 2012)
Section 3121(q) Notice and Demand —
Tax due on unreported tips
(Form 941 or 941-SS, line 5f (line 5e for
quarters ending before January 1, 2013))
Tax adjustments (Form 941 or
941-SS, lines 7–9)

.

—

.

=

.

× .009 =

.

.

—

.

=

.

Copy Column
3 here ▶

.

.

—

.

=

.

Copy Column
3 here ▶

.

14.

Special addition to wages for
federal income tax

.

—

.

=

.

See
instructions

.

15.

Special addition to wages for
social security taxes

.

—

.

=

.

See
instructions

.

16.

Special addition to wages for
Medicare taxes

.

—

.

=

.

See
instructions

.

17.

Combine the amounts on lines 7–16 of Column 4

18a.

COBRA premium assistance
payments (see instructions)

18b.

Number of individuals provided
COBRA premium assistance
(see instructions)

19.

Total. Combine the amounts on lines 17 and 18a of Column 4 .

.
.

.

.

.

.

.

.

.

—

.

.

.

.

.

.

.

.

=

.

.

.

.

.

.

.

See
instructions

.

.

=

—

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.

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.

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.

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.

If line 19 is less than zero:
• If you checked line 1, this is the amount you want applied as a credit to your Form 941 for the tax period in which you are filing this
form. (If you are currently filing a Form 944, Employer’s ANNUAL Federal Tax Return, see the instructions.)
• If you checked line 2, this is the amount you want refunded or abated.
If line 19 is more than zero, this is the amount you owe. Pay this amount by the time you file this return. For information on how to
pay, see Amount You Owe in the instructions.
Next ■▶
Page 2

Form 941-X (Rev. 4-2014)

Name (not your trade name)

Employer identification number (EIN)

Correcting quarter

(1, 2, 3, 4)

Correcting calendar year (YYYY)

Part 4: Explain your corrections for this quarter.
20.

Check here if any corrections you entered on a line include both underreported and overreported amounts. Explain both
your underreported and overreported amounts on line 22.

DRAFT AS OF
October 29, 2013
DO NOT FILE

21.

Check here if any corrections involve reclassified workers. Explain on line 22.

22.

You must give us a detailed explanation of how you determined your corrections. See the instructions.

Internal Use Only
DRAFT AS OF
October 25, 2013

Part 5: Sign here. You must complete all three pages of this form and sign it.

Under penalties of perjury, I declare that I have filed an original Form 941 or Form 941-SS and that I have examined this adjusted return or claim, including
accompanying schedules and statements, and to the best of my knowledge and belief, they are 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
Check if you are self-employed .

Paid Preparer Use Only
Preparer’s name

PTIN

Preparer’s signature

Date

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

EIN

Address

Phone

City
Page 3

State

/

.

.

/

ZIP code
Form 941-X (Rev. 4-2014)

Type of errors
you are
correcting

Form 941-X: Which process should you use?

Underreported
amounts
ONLY

Use the adjustment process to correct underreported amounts.
• Check the box on line 1.
• Pay the amount you owe from line 19 by the time you file Form 941-X.

Overreported
amounts
ONLY

The process you
use depends on
when you file
Form 941-X.

DRAFT AS OF
October 29, 2013
DO NOT FILE
If you are filing Form 941-X
MORE THAN 90 days before
the period of limitations on
credit or refund for Form 941
or Form 941-SS expires...

Choose either the adjustment process or the claim
process to correct the overreported amounts.
Choose the adjustment process if you want the
amount shown on line 19 credited to your Form 941,
Form 941-SS, or Form 944 for the period in which you
file Form 941-X. Check the box on line 1.
OR
Choose the claim process if you want the amount
shown on line 19 refunded to you or abated. Check
the box on line 2.

BOTH
underreported
and
overreported
amounts

The process you
use depends on
when you file
Form 941-X.

If you are filing Form 941-X
WITHIN 90 days of the
expiration of the period of
limitations on credit or refund
for Form 941 or Form 941-SS...

You must use the claim process to correct the
overreported amounts. Check the box on line 2.

If you are filing Form 941-X
MORE THAN 90 days before
the period of limitations on
credit or refund for Form 941
or Form 941-SS expires...

Choose either the adjustment process or both the
adjustment process and the claim process when you
correct both underreported and overreported
amounts.
Choose the adjustment process if combining your
underreported amounts and overreported amounts results
in a balance due or creates a credit that you want applied
to Form 941, Form 941-SS, or Form 944.
• File one Form 941-X, and
• Check the box on line 1 and follow the instructions
on line 19.
OR
Choose both the adjustment process and the
claim process if you want the overreported amount
refunded to you or abated.
File two separate forms.
1. For the adjustment process, file one Form 941-X
to correct the underreported amounts. Check the
box on line 1. Pay the amount you owe from line
19 by the time you file Form 941-X.
2. For the claim process, file a second Form 941-X
to correct the overreported amounts. Check the
box on line 2.

If you are filing Form 941-X
WITHIN 90 days of the
expiration of the period of
limitations on credit or
refund for Form 941 or
Form 941-SS...

You must use both the adjustment process and
the claim process.
File two separate forms.
1. For the adjustment process, file one Form 941-X to
correct the underreported amounts. Check the box
on line 1. Pay the amount you owe from line 19 by
the time you file Form 941-X.
2. For the claim process, file a second Form 941-X to
correct the overreported amounts. Check the box
on line 2.

Page 4

Form 941-X (Rev. 4-2014)