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Form (Rev.

October 2010) (EIN)

941 for 2010:

Employer’s QUARTERLY Federal Tax Return
Department of the Treasury — Internal Revenue Service — (Check one.)

951110
OMB No. 1545-0029

Employer identification number Name (not your trade name) Trade name (if any) Address
Number Street Suite or room number

Report for this Quarter of 2010
1: January, February, March 2: April, May, June 3: July, August, September 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 2 3 4 5a 5b 5c 5d 6a 6b 6c 6e 7a 7b 7c 8 9 10 11 12a 12b 12c 12d 13 14 15

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) Wages, tips, and other compensation . . . . . . . . . . . . . . . . . . . . . . . . .

1 2 3

Income tax withheld from wages, tips, and other compensation

. .
Check and go to line 6e.
*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.

If no wages, tips, and other compensation are subject to social security or Medicare tax Column 1 Taxable social security wages* . Taxable social security tips* . . . . .

Taxable Medicare wages & tips*

. . .

Column 2 × .124 = × .124 = × .029 = . . . . . . .

. . .
. . 5d

Add Column 2 line 5a, Column 2 line 5b, and Column 2 line 5c

.
See instructions for definitions of qualified employee and exempt wages/tips.

Number of qualified employees first paid exempt wages/tips this quarter Number of qualified employees paid exempt wages/tips this quarter Exempt wages/tips paid to qualified employees this quarter Total taxes before adjustments (line 3 + line 5d – line 6d = line 6e) . Current quarter’s adjustment for fractions of cents . Current quarter’s adjustment for sick pay . . . . . . . . . . . . . . . . . . . . . . . . .

.
. . . . . . . . . . . . . . . . . . . . . . . . . . .

× .062 = . . . . . . . . . . . . . . . . . . . . . . . . . . .

6d 6e 7a 7b 7c 8 9 10 11 12a

Current quarter’s adjustments for tips and group-term life insurance Total taxes after adjustments. Combine lines 6e through 7c . . .

Advance earned income credit (EIC) payments made to employees Total taxes after adjustment for advance EIC (line 8 – line 9 = line 10) Total deposits, including prior quarter overpayments . . . . . . . . . .

COBRA premium assistance payments (see instructions)

. . . . . . . . . .
Complete lines 12c, 12d, and 12e only for the 2nd quarter of 2010.

Number of individuals provided COBRA premium assistance .

Number of qualified employees paid exempt wages/tips March 19–31 Exempt wages/tips paid to qualified employees March 19–31 Add lines 11, 12a, and 12e . . . . . . . . . . . . . . .

.
. . .

× .062 = . . . . . .

12e 13 14
Apply to next return.

Balance due. If line 10 is more than line 13, enter the difference and see instructions Overpayment. If line 13 is more than line 10, enter the difference You MUST complete both pages of Form 941 and SIGN it.

.

. . .
Send a refund.

Check one:

Next ■▶
Cat. No. 17001Z Form 941 (Rev. 10-2010)

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

Preparer’s signature Firm’s name (or yours if self-employed) Date EIN Phone State ZIP code / / Form 941 (Rev. correct. If a question does NOT apply to your business. . Designee’s name and phone number Select a 5-digit Personal Identification Number (PIN) to use when talking to the IRS. If you are unsure about whether you are a monthly schedule depositor or a semiweekly schedule depositor. Yes. or another person to discuss this return with the IRS? See the instructions for details. . . . Line 10 on this return is less than $2. Check here. . . . Check here. . Complete Schedule B (Form 941): Report of Tax Liability for Semiweekly Schedule Depositors. . Part 5: Sign here. including accompanying schedules and statements. . . .500 or line 10 on the return for the preceding quarter was less than $2. ✗ Address City Page 2 Sign your name here Print your name here Print your title here / / Best daytime phone Check if you are self-employed . and to the best of my knowledge and belief. You MUST complete both pages of Form 941 and SIGN it. . see Pub. 16 17 Check one: Write the state abbreviation for the state where you made your deposits OR write “MU” if you made your deposits in multiple states. . Under penalties of perjury. and 19 If you are a seasonal employer and you do not have to file a return for every quarter of the year Part 4: May we speak with your third-party designee? Do you want to allow an employee. . enter the final date you paid wages / / . . section 11. . 10-2010) .000 next-day deposit obligation during the current quarter. Tax liability: Month 1 Month 2 Month 3 Total liability for quarter . Go to Part 3. . You were a monthly schedule depositor for the entire quarter. . Part 3: Tell us about your business. . I declare that I have examined this return. 18 If your business has closed or you stopped paying wages . and complete. No. and attach it to Form 941. 15 (Circular E).950210 Name (not your trade name) Employer identification number (EIN) Part 2: Tell us about your deposit schedule and tax liability for this quarter. a paid tax preparer. leave it blank. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.500. PTIN Date Paid preparer use only Preparer’s name . Enter your tax liability for each month and total liability for the quarter. and you did not incur a $100. You were a semiweekly schedule depositor for any part of this quarter. Total must equal line 10. it is true.

Box 3—Tax period. If you have your return prepared by a third party and make a payment with that return. Do not staple Form 941-V or your payment to Form 941 (or to each other). See section 11 of Pub. Employer's Tax Guide. Do not use Form 941-V to make federal tax deposits. Form Payment Voucher ▶ Do OMB No. Application for Employer Identification Number. Specific Instructions Box 1—Employer identification number (EIN). • Detach Form 941-V and send it with your payment and Form 941 to the address in the Instructions for Form 941. Enter your city. Caution. or • You are a monthly schedule depositor making a payment in accordance with the Accuracy of Deposits Rule. 3 Tax Period 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Enter your address.500. You must also complete the entity information above Part 1 on Form 941. Employer’s QUARTERLY Federal Tax Return. ▼ 941-V Enter your employer identification number (EIN). If you do not have an EIN. please provide this payment voucher to the return preparer. Otherwise. • Enclose your check or money order made payable to the "United States Treasury. you may be subject to a penalty. you must deposit your payment by using the Electronic Federal Tax Payment System (EFTPS). and write “Applied For” and the date you applied in this entry space. "Form 941. ✁ Department of the Treasury Internal Revenue Service ▼ Detach Here and Mail With Your Payment and Form 941. 15 (Circular E) for deposit instructions. Box 4—Name and address. We will use the completed voucher to credit your payment more promptly and accurately. Note. 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. 15 (Circular E). Payment Voucher." Be sure to enter your EIN. However. Darken the circle identifying the quarter for which the payment is made. 2 Dollars 2010 Cents 1 Enter the amount of your payment. for details. apply for one on Form SS-4. Box 2—Amount paid. ▶ 4 Enter your business name (individual name if sole proprietor). if you are making a payment with Form 941. you did not incur a $100." and the tax period on your check or money order. Enter your name and address as shown on Form 941.Form 941-V. See Deposit Penalties in section 11 of Pub. Making Payments With Form 941 To avoid a penalty. if you pay an amount with Form 941 that should have been deposited. the amount of your payment may be $2. In this case. ✃ . 1545-0029 not staple this voucher or your payment to Form 941. Payment Voucher Purpose of Form Complete Form 941-V. Do not send cash. and to improve our service to you. and you are paying in full with a timely filed return.500 or more. Use Form 941-V when making any payment with Form 941.000 next-day deposit obligation during the current quarter. 15 (Circular E). Enter the amount paid with Form 941. state. and ZIP code. See section 11 of Pub. Darken only one circle.

copying. Employment Taxes. or provide false or fraudulent information. The time needed to complete and file Form 941 will vary depending on individual circumstances. 1 hr. Do not send Form 941 to this address. Section 6109 requires you to provide your identification number. . DC 20224. to federal and state agencies to enforce federal nontax criminal laws. Preparing. you may be subject to penalties and interest. 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. states. and U. we would be happy to hear from you. 52 min. see Where Should You File? in the Instructions for Form 941. . We may also disclose this information to other countries under a tax treaty. the District of Columbia. Form 941 is used to determine the amount of taxes that you owe. . including income tax withholding. Subtitle C. Instead. as required by section 6103. 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. . 13 hr. . 47 min. Learning about the law or the form . For example. 1111 Constitution Ave. . tax returns and return information are confidential. and sending the form to the IRS . 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. The estimated average time is: Recordkeeping . assembling. If you fail to provide this information in a timely manner. 3 min. SE:W:CAR:MP:T:T:SP. commonwealths and possessions for use in administering their tax laws. . NW. . IR-6526. . . . or to federal law enforcement and intelligence agencies to combat terrorism.. . . If you have comments concerning the accuracy of these time estimates or suggestions for making Form 941 simpler. . Tax Products Coordinating Committee. You can write to: Internal Revenue Service. Generally.Form 941 (Rev. and to cities.S. 10-2010) Privacy Act and Paperwork Reduction Act Notice. However.. . Section 6011 requires you to provide the requested information if the tax is applicable to you. we may disclose your tax information to the Department of Justice for civil and criminal litigation. . . Washington. We ask for the information on Form 941 to carry out the Internal Revenue laws of the United States. We need it to figure and collect the right amount of tax. of the Internal Revenue Code imposes employment taxes on wages.