Form 5884-D Employee Retention Credit for Certain Tax-Exempt Organiz

Version A, Cycle 5

Form

5884-D

Employee Retention Credit for Certain Tax-Exempt
Organizations Affected by Qualified Disasters

(March 2021)

OMB No. 1545-0047

▶ File

this form separately; do not attach it to your return.
▶ Go to www.irs.gov/Form5884D for instructions and the latest information.

Department of the Treasury
Internal Revenue Service

Employer identification number

Name (not trade name) shown on Form 941 or other employment tax return
Trade name (if any)
Number, street, and room or suite no. If a P.O. box, see instructions.
City or town, state, and ZIP code

1

If filed by a third-party payer, identify the qualified tax-exempt organization here. See instructions. Check

if not applicable.

Employer identification number

Name
Number, street, and room or suite no. If a P.O. box, see instructions.
City or town, state, and ZIP code

2a

Is the organization a qualified tax-exempt organization (an organization described in section 501(c) and
exempt from tax under section 501(a))? See instructions . . . . . . . . . . . . . . . . .
b Is the organization a federally chartered corporation, or is it a federal, state, or local college, university,
hospital, or medical care entity? See instructions . . . . . . . . . . . . . . . . . . . .
If you checked “Yes,” on either line 2a or 2b, go to line 3. If you checked “No” on both lines 2a and 2b, do
not file this form; the organization cannot claim this credit.
3
Applicable 2020 qualified disaster zone(s) (see instructions):

Yes

No

Yes

No

INTERNAL USE ONLY
DRAFT AS OF
February 24, 2021
(a)
Disaster declaration
number

DR -

-

DR -

-

DR -

-

DR -

-

(b)
Description

(c)
County name(s)

4

Check a box to indicate the employment tax return the organization filed to report wages paid to an eligible employee:
a
Form 941 b
Form 941-PR c
Form 941-SS d
Form 943 e
Form 943-PR
g
f
Form 944 (or 944(SP))
Form 944-PR h
Form 944-SS
5
Check a box or boxes to indicate the employment tax period for which the organization is claiming this credit. See instructions:
a Check year:
2019 (4th quarter only)
2020
2021 (1st and 2nd quarters only)
b Check quarter (if applicable):
1st: January, February, March
2nd: April, May, June
3rd: July, August, September
4th: October, November, December
Carryforward only, for
(year),
(quarter)
6a

Enter the organization’s total qualified wages for the 2020 qualified disaster
employee retention credit paid through the end of the employment tax period
indicated on line 5 to all eligible employees (up to $6,000 each). See instructions
6a
b Multiply line 6a by 40% (0.40) . . . . . . . . . . . . . . . . . . . . . . . .
7
Enter the number of eligible employees who earned the qualified wages for the 2020 qualified disaster
employee retention credit on line 6a (which cannot exceed $6,000 times this number)
. . . . .
For Paperwork Reduction Act Notice, see instructions.

Cat. No. 75321C

6b
7

Form 5884-D (3-2021)

Version A, Cycle 5
Form 5884-D (3-2021)

Page

2

8

Enter the total amount of 2020 qualified disaster employee retention credits claimed on line 12 of any
Forms 5884-D filed for prior employment tax periods by or on behalf of the organization. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Note: If line 8 is greater than line 6b, skip lines 9 through 12 and go to line 13. Otherwise, go to line 9.
9
Subtract line 8 from line 6b . . . . . . . . . . . . . . . . . . . . . . . . .
10
Enter the organization’s total taxable social security wages and tips reported on the return indicated
on line 4 for the period indicated on line 5. See instructions . . . . . . . . . . . . . .
Note: If you filed a corrected return (for example, Form 941-X) for the period indicated on line 5, enter
the amount as corrected.
11a Multiply line 10 by 6.2% (0.062) . . . . . . . . . . . . . . .
11a
b If you filed Form 5884-C for the period indicated on line 5 of this form, enter the
total amount of credits claimed on line 11 of Form 5884-C. See instructions .
11b

8
9
10

c

Enter the total amount of any qualified small business payroll tax credit for
increasing research activities (Form 941, Form 943, or Form 944) filed for the
period indicated on line 5 of this form. See instructions . . . . . . . .
d Add lines 11b and 11c and subtract the total from line 11a. If the result is less
than zero, enter -0. . . . . . . . . . . . . . . . . . .
12

13

11c
11d

Credit claimed for the employment tax period indicated on line 5. Enter the smaller of line 9 or line
11d. This is the amount that will be allowed. Stop here, sign, and mail this form to the address below.
See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If line 8 is greater than line 6b, subtract line 6b from line 8. This is the amount you owe. Sign and mail
this form to the address below with your payment for this amount. See instructions . . . . . .

12

INTERNAL USE ONLY
DRAFT AS OF
February 24, 2021
13

Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, correct, and complete. Declaration of preparer is based on all information of which preparer has any knowledge.
Daytime telephone number

Sign
Here

Signature of officer

Paid
Preparer
Use Only

Print/Type preparer’s name

Date

Title

Preparer’s signature

Date

Check
if
self-employed

Firm’s name

▶

Firm’s EIN

Firm’s address

▶

Phone no.

PTIN

▶

Send Form 5884-D to: Department of the Treasury, Internal Revenue Service, Ogden, UT 84201

Form 5884-D (3-2021)