Form 941 (rev. April 2009)
Form 941 for 2009: Employer’s QUARTERLY Federal Tax Return
950109
OMB No. 1545-0029
(Rev. April 2009)
Department of the Treasury — Internal Revenue Service
(EIN)
—
Report for this Quarter of 2009
Employer identification number
(Check one.)
Name (not your trade name)
1: January, February, March
Trade name (if any)
2: April, May, June
3: July, August, September
Address
Number
Street
Suite or room number
4: October, November, December
City
State
ZIP code
Read the separate instructions before you complete Form 941. 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), Dec. 12 (Quarter 4)
1
.
2
Wages, tips, and other compensation
2
3
Income tax withheld from wages, tips, and other compensation
3
.
4
If no wages, tips, and other compensation are subject to social security or Medicare tax
Check and go to line 6.
5
Taxable social security and Medicare wages and tips:
Column 1
Column 2
.
.
5a Taxable social security wages
.124 =
.
5b Taxable social security tips
.124 =
.
.
5c Taxable Medicare wages & tips
.029 =
.
.
5d Total social security and Medicare taxes (Column 2, lines 5a + 5b + 5c = line 5d)
5d
6
Total taxes before adjustments (lines 3 + 5d = line 6)
6
.
7
CURRENT QUARTER’S ADJUSTMENTS, for example, a fractions of cents adjustment.
See the instructions.
.
7a Current quarter’s fractions of cents
7b Current quarter’s sick pay
.
7c Current quarter’s adjustments for tips and group-term life insurance
.
.
7d TOTAL ADJUSTMENTS. Combine all amounts on lines 7a through 7c
7d
8
Total taxes after adjustments. Combine lines 6 and 7d
8
.
9
Advance earned income credit (EIC) payments made to employees
9
.
10
Total taxes after adjustment for advance EIC (line 8 – line 9 = line 10)
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
12a COBRA premium assistance payments (see instructions)
.
12b Number of individuals provided COBRA premium
assistance reported on line 12a
13
Add lines 11 and 12a
13
.
.
14
Balance due. If line 10 is more than line 13, write the difference here
14
For information on how to pay, see the instructions.
Apply to next return.
.
15
Overpayment. If line 13 is more than line 10, write the difference here
Check one
Send a refund.
You MUST complete both pages of Form 941 and SIGN it.
Next
For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.
Cat. No. 17001Z
Form 941 (Rev. 4-2009)
950209
Name (not your trade name)
Employer identification number (EIN)
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. 15
(Circular E), section 11.
Write the state abbreviation for the state where you made your deposits OR write “MU” if you made your
16
deposits in multiple states.
17 Check one:
Line 10 is less than $2,500. Go to Part 3.
You were a monthly schedule depositor for the entire quarter. Enter your tax liability
for each month. Then go to Part 3.
Tax liability:
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.
Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank.
18 If your business has closed or you stopped paying wages
Check here, and
enter the final date you paid wages
/
/
.
19 If you are a seasonal employer and you do not have to file a return for every quarter of the year
Check here.
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 the IRS.
No.
Part 5: Sign here. You MUST complete both pages of Form 941 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
Sign your
name here
name here
Print your
title here
(
)
–
Date
/
/
Best daytime phone
Paid preparer’s use only
Check if you are self-employed
Preparer’s
Preparer’s name
SSN/PTIN
Preparer’s signature
Date
/
/
Firm’s name (or yours
EIN
if self-employed)
Address
Phone
(
)
–
City
State
ZIP code
Page 2
Form 941 (Rev. 4-2009)
Form 941-V,
Payment Voucher
Purpose of Form
Caution. Use Form 941-V when making any payment
with Form 941. However, if you pay an amount with
Complete Form 941-V, Payment Voucher, if you are
Form 941 that should have been deposited, you may
making a payment with Form 941, Employer’s
be subject to a penalty. See Deposit Penalties in
QUARTERLY Federal Tax Return. We will use the
section 11 of Pub. 15 (Circular E).
completed voucher to credit your payment more
promptly and accurately, and to improve our service to
Specific Instructions
you.
Box 1—Employer identification number (EIN). If you
If you have your return prepared by a third party and
do not have an EIN, apply for one on Form SS-4,
make a payment with that return, please provide this
Application for Employer Identification Number, and
payment voucher to the return preparer.
write “Applied For” and the date you applied in this
entry space.
Making Payments With Form 941
Box 2—Amount paid. Enter the amount paid with
To avoid a penalty, make your payment with Form 941
Form 941.
only if:
●
Box 3—Tax period. Darken the capsule identifying the
Your net taxes for the quarter (line 10 on Form 941)
quarter for which the payment is made. Darken only
are less than $2,500 and you are paying in full with a
one capsule.
timely filed return or
●
Box 4—Name and address. Enter your name and
You are a monthly schedule depositor making a
address as shown on Form 941.
payment in accordance with the Accuracy of Deposits
Rule. See section 11 of Pub. 15 (Circular E),
● Enclose your check or money order made payable to
Employer’s Tax Guide, for details. In this case, the
the “United States Treasury.” Be sure to enter your
amount of your payment may be $2,500 or more.
EIN, “Form 941,” and the tax period on your check or
money order. Do not send cash. Do not staple Form
Otherwise, you must deposit your payment at an
941-V or your payment to Form 941 (or to each other).
authorized financial institution or by using the
Electronic Federal Tax Payment System (EFTPS). See
● Detach Form 941-V and send it with your payment
section 11 of Pub. 15 (Circular E) for deposit
and Form 941 to the address in the Instructions for
instructions. Do not use Form 941-V to make federal
Form 941.
tax deposits.
Note. You must also complete the entity information
above Part 1 on Form 941.
Ê
Detach Here and Mail With Your Payment and Form 941.
¡
OMB No. 1545-0029
941-V
Payment V
oucher
Form
Department of the Treasury
Do not staple this voucher or your payment to Form 941.
2009
Internal Revenue Service
1 Enter your employer identification
2
Dollars
Cents
number (EIN).
Enter the amount of your payment.
3 Tax period
4 Enter your business name (individual name if sole proprietor).
1st
3rd
Quarter
Quarter
Enter your address.
2nd
4th
Enter your city, state, and ZIP code.
Quarter
Quarter
Form 941 (Rev. 4-2009)
Privacy Act and Paperwork Reduction Act Notice.
Justice for civil and criminal litigation, and to cities,
We ask for the information on Form 941 to carry out
states, the District of Columbia, and U.S.
the Internal Revenue laws of the United States. We
commonwealths and possessions for use in
need it to figure and collect the right amount of tax.
administering their tax laws. We may also disclose this
Subtitle C, Employment Taxes, of the Internal Revenue
information to other countries under a tax treaty, to
Code imposes employment taxes on wages, including
federal and state agencies to enforce federal nontax
income tax withholding. This form is used to determine
criminal laws, or to federal law enforcement and
the amount of the taxes that you owe. Section 6011
intelligence agencies to combat terrorism.
requires you to provide the requested information if the
The time needed to complete and file Form 941 will
tax is applicable to you. Section 6109 requires filers
vary depending on individual circumstances. The
and paid preparers to provide their identifying
estimated average time is:
numbers. If you fail to provide this information in a
timely manner, you may be subject to penalties and
Recordkeeping
12 hr., 39 min.
interest.
Learning about the law or the form
40 min.
You are not required to provide the information
Preparing the form
1 hr., 49 min.
requested on a form that is subject to the Paperwork
Reduction Act unless the form displays a valid OMB
Copying, assembling, and sending
control number. Books and records relating to a form
the form to the IRS
16 min.
or instructions must be retained as long as their
If you have comments concerning the accuracy of
contents may become material in the administration of
these time estimates or suggestions for making Form
any Internal Revenue law.
941 simpler, we would be happy to hear from you. You
can write to: Internal Revenue Service, Tax Products
Generally, tax returns and return information are
Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111
confidential, as required by section 6103. However,
Constitution Ave. NW, IR-6526, Washington, DC
section 6103 allows or requires the IRS to disclose or
20224. Do not send Form 941 to this address. Instead,
give the information shown on your tax return to others
see Where Should You File? on page 4 of the
as described in the Code. For example, we may
Instructions for Form 941.
disclose your tax information to the Department of
