Fillable Printable Form 941 (Rev. October 2010)
Fillable Printable Form 941 (Rev. October 2010)
Form 941 (Rev. October 2010)
Form 941 for 2010:
(Rev. October 2010)
Employer’s QUARTERLY Federal Tax Return
Department of the Treasury — Internal Revenue Service
951110
OMB No. 1545-0029
(EIN)
Employer identification number
—
Name (not your trade name)
Trade name (if any)
Address
Number Street Suite or room number
CityStateZIP code
Report for this Quarter of 2010
(Check one.)
1: January, February, March
2: April, May, June
3: July, August, September
4: October, November, December
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), or Dec. 12 (Quarter 4)
1
2Wages, tips, and other compensation .................2
.
3Income tax withheld from wages, tips, and other compensation ........3
.
4If no wages, tips, and other compensation are subject to social security or Medicare taxCheck and go to line 6e.
Column 1Column 2
*Report wages/tips for this quarter,
including those paid to qualified
new employees, on lines 5a–5c.
The social security tax exemption
on wages/tips will be figured on
lines 6c and 6d and will reduce the
tax on line 6e.
5
aTaxable social security wages* ..
.
× .124 =
.
5
b
Taxable social security tips*...
.
× .124 =
.
5
c
Taxable Medicare wages & tips*.
.
× .029 =
.
5
d
Add Column 2 line 5a, Column 2 line 5b, and Column 2 line 5c .........5d
.
6a
Number of qualified employees first paid exempt wages/tips this quarter
See instructions for definitions of
qualified employee and
exempt wages/tips.
6b
Number of qualified employees paid exempt wages/tips this quarter
6
c
Exempt wages/tips paid to qualified employees this quarter
.
× .062 =
6d
.
6eTotal taxes before adjustments (line 3 + line 5d – line 6d = line 6e).........6e
.
7aCurrent quarter’s adjustment for fractions of cents .............7a
.
7bCurrent quarter’s adjustment for sick pay ................7b
.
7c
Current quarter’s adjustments for tips and group-term life insurance .......
7c
.
8Total taxes after adjustments. Combine lines 6e through 7c...........8
.
9Advance earned income credit (EIC) payments made to employees .......9
.
10Total taxes after adjustment for advance EIC (line 8 – line 9 = line 10) .......10
.
11
Total deposits, including prior quarter overpayments ............
11
.
12aCOBRA premium assistance payments (see instructions) ...........
12a
.
12b
Number of individuals provided COBRA premium assistance ..
Complete lines 12c, 12d, and 12e
only for the 2nd quarter of 2010.
12c
Number ofqualified employees paid exempt wages/tips March 19–31
12
d
Exempt wages/tips paid to qualified employees March 19–31
.
× .062 =
12e
.
13Add lines 11, 12a, and 12e .....................13
.
14Balance due. If line 10 is more than line 13, enter the difference and see instructions...14
.
15
Overpayment.
If line 13 is more than line 10, enter the difference
.
Check one:
Apply to next return.
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. 10-2010)
950210
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.
16
Write the state abbreviation for the state where you made your deposits OR write “MU” if you made your
deposits in multiple states.
17Check one:
Line 10 on this return is less than $2,500 or line 10 on the return for the preceding quarter was less than $2,500,
and you did not incur a $100,000 next-day deposit obligation during the current quarter. 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.
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. CompleteSchedule 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.
18If your business has closed or you stopped paying wages ...............Check here, and
enter the final date you paid wages
/ / .
19If 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.
✗
Sign your
name here
Print your
name here
Print your
title here
Date/ /Best daytime phone
Paid preparer use only
Check if you are self-employed ...
Preparer’s name
Preparer’s signature
Firm’s name (or yours
if self-employed)
Address
CityState
PTIN
Date/ /
EIN
Phone
ZIP code
Page 2Form 941 (Rev. 10-2010)
Form 941-V,
Payment Voucher
Purpose of Form
Complete Form 941-V, Payment Voucher, if you are
making a payment with Form 941, 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.
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 941
To avoid a penalty, make your payment with Form 941
only if:
• Your net taxes for either the current quarter or the
preceding quarter (line 10 on Form 941) are less than
$2,500, you did not incur a $100,000 next-day 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 11 of Pub. 15 (Circular E), Employer's
Tax Guide, for details. In this case, the amount of your
payment may be $2,500 or more.
Otherwise, you must deposit your payment by using
the Electronic Federal Tax Payment System (EFTPS). See
section 11 of Pub. 15 (Circular E) for deposit instructions.
Do not use Form 941-V to make federal tax deposits.
Caution. Use Form 941-V when making any paymentwith
Form 941. However, if you pay an amount withForm 941
that should have been deposited, you maybe subject to a
penalty. SeeDeposit Penalties insection 11 of Pub. 15
(Circular E).
Specific Instructions
Box 1—Employer identification number (EIN). If youdo
not have an EIN, apply for one on Form SS-4,Application
for Employer Identification Number, andwrite “Applied
For” and the date you applied in thisentry space.
Box 2—Amount paid. Enter the amount paid with
Form 941.
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.
• Enclose your check or money order made payable to
the "United States Treasury." Be sure to enter your
EIN, "Form 941," and the tax period on your check or
money order. Do not send cash. Do not staple Form
941-V or your payment to Form 941 (or to each other).
• Detach Form 941-V and send it with your payment
and Form 941 to the address in the Instructions for
Form 941.
Note. You must also complete the entity information
above Part 1 on Form 941.
✁
▼
Detach Here and Mail With Your Payment and Form 941.
▼
✃
Form
941-V
Department of the Treasury
Internal Revenue Service
Payment Voucher
▶
Do not staple this voucher or your payment to Form 941.
OMB No. 1545-0029
2010
1Enter your employer identification
number (EIN).
2
Enter the amount of your payment.
▶
DollarsCents
3Tax Period
1st
Quarter
2nd
Quarter
3rd
Quarter
4th
Quarter
4Enter your business name (individual name if sole proprietor).
Enter your address.
Enter your city, state, and ZIP code.
Form 941 (Rev. 10-2010)
Privacy Act and Paperwork Reduction Act Notice.
We ask for the information on Form 941 to carry outthe
Internal Revenue laws of the United States. Weneed it to
figure and collect the right amount of tax.Subtitle C,
Employment Taxes, of the Internal RevenueCode
imposes employment taxes on wages, includingincome
tax withholding. Form 941 is used to determinethe
amount of taxes that you owe. Section 6011requires you
to provide the requested information if thetax is
applicable to you. Section 6109 requires you to provide
your identification number. If you fail to provide this
information in atimely manner, or provide false or
fraudulent information, you may be subject to penalties
andinterest.
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
its 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 will
vary depending on individual circumstances. The
estimated average time is:
Recordkeeping..........13 hr., 52 min.
Learning about the law or the form....47 min.
Preparing, copying, assembling, and
sending the form to the IRS..... 1 hr., 3 min.
If you have comments concerning the accuracy of
these time estimates or suggestions for making Form 941
simpler, we would be happy to hear from you. You can
write to: Internal Revenue Service, Tax Products
Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111
Constitution Ave. NW, IR-6526, Washington, DC 20224.
Do not send Form 941 to this address. Instead, see
Where Should You File? in the Instructions for Form 941.
