944-SS (2011) Employer's ANNUAL Federal Tax Return (American Samoa, Gu

Form

944-SS for 2011:

Employer’s ANNUAL Federal Tax Return

Department of the Treasury — Internal Revenue Service

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

Who Must File Form 944-SS

—

Employer identification number (EIN)

OMB No. 1545-2010

You must file annual
Form 944-SS instead of
filing quarterly Forms
941-SS only if the IRS
notified you in writing.
Prior-year forms are
available at www.irs.gov/
form944ss.

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

Street

Suite or room number

City

ZIP code

State

Read the separate instructions before you complete Form 944-SS. Type or print within the boxes.
Answer these questions for this year.
Part 1:
1
2
3

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

4

Taxable social security and Medicare wages and tips:
Column 1
4a Taxable social security wages
4b Taxable social security tips
4c Taxable Medicare wages & tips

Column 2

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× .104 =
× .104 =
× .029 =

3

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Check and go to line 6.

For 2011, the employee social security tax
rate is 4.2% and the Medicare tax rate is
1.45%. The employer social security tax
rate is 6.2% and the Medicare tax rate is
1.45%.

4d Add Column 2, line 4a, Column 2, line 4b, and Column 2, line 4c .

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6

Current year’s adjustments (see instructions)

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6

7

Total taxes after adjustments. Combine lines 4d and 6

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7

8

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

8

9a

COBRA premium assistance payments (see instructions)

9b

Number of individuals provided COBRA premium assistance

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4d

5
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9a

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10

Add lines 8 and 9a .

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10

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11

Balance due. If line 7 is more than line 10, enter the difference and see instructions .

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11

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Overpayment. If line 10 is more than line 7, enter the difference
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Check one:

Apply to next return.

Send a refund.

You MUST complete both pages of Form 944-SS and SIGN it.

Next ■▶
For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.

Cat. No. 47935C

Form 944-SS (2011)

Name (not your trade name)

Part 2:

Employer identification number (EIN)

Tell us about your deposit schedule and tax liability for this year.
Line 7 is less than $2,500. Go to Part 3.

13 Check one:

Line 7 is $2,500 or more. Enter your tax liability for each month. If you are a semiweekly depositor or you accumulate
$100,000 or more of liability on any day during a deposit period, you must complete Form 945-A instead of the boxes below.
Jan.

13a
Feb.

13b
Mar.

13c

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Apr.

13d
May

13e
Jun.

13f

Jul.

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13g
Aug.

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13h
Sep.

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13i

Total liability for year. Add lines 13a through 13l. Total must equal line 7.

Oct.

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13j
Nov.

13k

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Dec.

13l

13m

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14

Part 3:

Tell us about your business. If question 15 does NOT apply to your business, leave it blank.

15 If your business has closed or you stopped paying wages . . .
Check here and enter the final date you paid wages

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 944-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 944-SS (2011)

Form 944-V(SS),
Payment Voucher
Purpose of Form
Complete Form 944-V(SS), Payment Voucher, if you are
making a payment with Form 944-SS, Employer’s
ANNUAL Federal Tax Return. We will use the completed
voucher to credit your payment more promptly and
accurately, and to improve our service to you.
If you have your return prepared by a third party and
make a payment with that return, please provide this
payment voucher to the return preparer.

Making Payments With Form 944-SS
To avoid a penalty, make your payment with your 2011
Form 944-SS only if one of the following applies.
• Your net taxes for the year (line 7 on Form 944-SS) are
less than $2,500 and you are paying in full with a timely
filed return.
• You already deposited the taxes you owed for the first,
second, and third quarters of 2011, and the tax you owe
for the fourth quarter of 2011 is less than $2,500, and you
are paying, in full, the tax you owe for the fourth quarter
of 2011 with a timely filed return.
• 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

Form

Specific Instructions
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 Employer
Identification Number (EIN) Online link. 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. If you have not received your EIN
by the due date of Form 944-SS, write “Applied For” and
the date you applied in this entry space.
Box 2—Amount paid. Enter the amount paid with Form
944-SS.
Box 3—Name and address. Enter your name and
address as shown on Form 944-SS.
• Enclose your check or money order made payable to
the “United States Treasury” and write your EIN, “Form
944-SS,” and “2011” on your check or money order. Do
not send cash. Do not staple Form 944-V(SS) or your
payment to Form 944-SS (or to each other).
• Detach Form 944-V(SS) and send it with your payment
and Form 944-SS to the address provided in the
Instructions for Form 944-SS.
Note. You must also complete the entity information
above Part 1 on Form 944-SS.

Detach Here and Mail With Your Payment and Form 944-SS.
▼

▼

944-V(SS)

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

✃

✁

instructions. Do not use Form 944-V(SS) to make federal
tax deposits.
Caution. Use Form 944-V(SS) when making any payment
with Form 944-SS. However, if you pay an amount with
Form 944-SS that should have been deposited, you may
be subject to a penalty. See Deposit Penalties in section 8
of Pub. 80 (Circular SS).

OMB No. 1545-2010

Payment Voucher
▶

Do not staple this voucher or your payment to Form 944-SS.
2

Dollars

Enter the amount of your payment.
3

2011

▶

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

Cents

Form 944-SS (2011)

Privacy Act and Paperwork Reduction Act Notice. We
ask for the information on this form 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. This form 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 and interest.
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 this form will vary
depending on individual circumstances. The estimated
average time is:
Recordkeeping . . . . . . . . . . 8 hr., 36 min.
Learning about the law or the form . . . . 24 min.
Preparing, copying, assembling,
and sending the form to the IRS . . . . . 33 min.
If you have comments concerning the accuracy of
these time estimates or suggestions for making
Form 944-SS simpler, we would be happy to hear from
you. You can email us at taxforms@irs.gov. Enter
“Form 944-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 944-SS to this address. Instead, see Where Should
You File? in the Instructions for Form 944-SS.