Form

941

Employer’s Quarterly Federal Tax Return
See separate instructions for information on completing this return.
Please type or print.

(Rev. January 2001)

Department of the Treasury Internal Revenue Service

Enter state

code for state

Name (as distinguished from trade name)

Date quarter ended

in which

deposits were

made only if

Trade name, if any

Employer identification number

different from

state in

Address (number and street)

City, state, and ZIP code

address to

the right

(see page

2 of

instructions).

1

1

1

1

1

1

1

1

1

1

2

33333333

444

555

If address is

different

from prior

return, check

here

6

7

 8 8 8 88 8 8 8

 9 9 9 9 9

10 10 10 10 10 10 10 10 10 10

If you do not have to file returns in the future, check here

and enter date final wages paid

If you are a seasonal employer, see Seasonal employers on page 1 of the instructions and check here

1 Number of employees in the pay period that includes March 12th

1

2 Total wages and tips, plus other compensation

	

3 Total income tax withheld from wages, tips, and sick pay

	

4 Adjustment of withheld income tax for preceding quarters of calendar year

	

5 Adjusted total of income tax withheld (line 3 as adjusted by line 4—see instructions)

6 Taxable social security wages

	

6a

× 12.4% (.124) =

Taxable social security tips

	

7Taxable Medicare wages and tips

8 Total social security and Medicare taxes (add lines 6b, 6d, and 7b). Check here if wages

are not subject to social security and/or Medicare tax

	

9 Adjustment of social security and Medicare taxes (see instructions for required explanation)

Sick Pay $

± Fractions of Cents $

± Other $

10 Adjusted total of social security and Medicare taxes (line 8 as adjusted by line 9—see instructions)

	

11

Total taxes (add lines 5 and 10)

	

12Advance earned income credit (EIC) payments made to employees

	

13 Net taxes (subtract line 12 from line 11). If $2,500 or more, this must equal line 17, column (d) below (or line D of Schedule B (Form 941))

14 Total deposits for quarter, including overpayment applied from a prior quarter

	

15 Balance due (subtract line 14 from line 13). See instructions

	

16 Overpayment. If line 14 is  more than line 13, enter excess here	$

and check if to be:

Applied to next return or

Refunded.

●	All filers: If line 13 is less than $2,500, you need not complete line 17 or Schedule B (Form 941).
●	Semiweekly schedule depositors: Complete Schedule B (Form 941) and check here

	

●	Monthly schedule depositors: Complete line 17, columns (a) through (d), and check here

	

17 Monthly Summary of Federal Tax Liability. Do not complete if you were a semiweekly schedule depositor.

Sign

Print Your

Name and Title

Date

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.

Here

Signature

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

Cat. No. 17001Z

Form 941 (Rev. 1-2001)

OMB No. 1545-0029	
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2			
3			
4			
5			
6b			

6c			×12.4% (.124) =	6d			
7a			×	2.9% (.029) =	7b			

8			
9			
10			
11			
12			
13			
14			
15			

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(a) First month liability	(b) Second month liability	(c) Third month liability	(d) Total liability for quarter	

Form 941 (Rev. 1-2001)

Where to file. In the list below, find the state where your legal residence, principal place of business, office, or agency is located. Send your return to the Internal Revenue Service at the address listed for your location. No

street address is needed. Note: Where you file depends on whether or not you are including a payment.

Florida, Georgia

Kansas, New Mexico, Oklahoma

Return without payment: Atlanta, GA 39901-0005

Return with payment: P.O. Box 105703

Return without payment: Austin, TX 73301-0005

Return with payment:

P.O. Box 970013

Atlanta, GA 30348-5703

St. Louis, MO 63197-0013

New York (New York City and counties of Nassau, Rockland, Suffolk, and Westchester)

Alaska, Arizona, Arkansas, California (counties of Alpine, Amador, Butte, Calaveras, Colusa, Contra

Costa, Del Norte,

Dorado, Glenn, Humboldt, Lake,

Return without payment: Holtsville, NY 00501-0005

Return with payment:
P.O. Box 416

Lassen, Marin, Mendocino, Modoc, Napa, Nevada, Placer, Plumas, Sacramento, San Joaquin, Shasta, Sierra, Siskiyou, Solano, Sonoma, Sutter, Tehama, Trinity, Yolo, and Yuba), Colorado, Hawaii, Idaho, Iowa, Louisiana, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Texas, Utah, Washington, Wyoming

Newark, NJ 07101-0416

New York (all other counties), Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

Return without payment: Andover, MA 05501-0005

Return with payment: P.O. Box 371493

Return without payment: Ogden, UT 84201-0005

Return with payment:

P.O. Box 7922

Pittsburgh, PA 15250-7493

San Francisco, CA 94120-7922

California (all other counties)

Illinois

Return without payment: Fresno, CA 93888-0005

Return with payment:

Return without payment: Kansas City, MO 64999-0005

Return with payment: P.O. Box 970007

P.O. Box 60407

Los Angeles, CA 90060-0407

St. Louis, MO 63197-0007

Alabama, Tennessee

Return without payment: Memphis, TN 37501 -0005

Return with payment:

Delaware, District of Columbia, Indiana, Kentucky, Maryland, Michigan, New Jersey, North Carolina, Ohio, Pennsylvania, South Carolina, West Virginia, Wisconsin

P.O. Box 70503

Charlotte, NC 28272-0503

Return without payment: Cincinnati, OH 45999-0005

Return with payment: P.O. Box 7329

If you have no legal residence or principal place of business in any state

All returns:

Chicago, IL 60680-7329

Philadelphia, PA 19255-0005

Virginia

Return without payment: Philadelphia, PA 19255-0005

Return with payment:

P.O. Box 8786

Philadelphia, PA 19162-8786

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Form 941

Payment Voucher

Purpose of Form

Specific Instructions

Complete Form 941-V 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.

Box 1. Enter the first four characters of your name as

follows:

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.

S Individuals (sole proprietors, estates). Use the first four letters of your last name (as shown in box 5).
S Corporations. Use the first four characters (letters or numbers) of your business name (as shown in box 5). Omit “The” if followed by more than one word.
S Partnerships. Use the first four characters of your trade name. If no trade name, enter the first four letters of the last name of the first listed partner.

Making Payments With Form 941

Make payments with Form 941 only if:

Box 2—Employer identification number (EIN). If you do not have an EIN, apply for one on Form SS-4, Application for Employer Identification Number, and write “Applied for” and the date you applied in this entry space.

1. Your net taxes for the quarter (line 13 on Form 941) are less than $2,500 or

2. You are a monthly schedule depositor making a payment in accordance with the accuracy of deposits rule. (See section 11 of Circular E, Employer’s Tax Guide, for details.) This amount may be $2,500 or more.

Box 3—Amount paid. Enter the amount paid with Form 941.

Otherwise, you must deposit the amount at an authorized financial institution or by electronic funds transfer. (See section 11 of Circular E for deposit instructions.) Do not use the Form 941-V payment voucher to make Federal tax deposits.

Box 4—Tax period. Darken the capsule identifying the quarter for which the payment is made. Darken only one capsule.

Box 5—Name and address. Enter your name and address as shown on Form 941.

Caution: If you pay amounts with Form 941 that should have been deposited, you may be subject to a penalty. See Circular E.

S Make your check or money order 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. Please do not staple this voucher or your payment to the return or to each

other.

S Detach the completed voucher and send it with your payment and Form 941 to the address provided on the back of Form 941.

Detach Here and Mail With Your Payment

Form 941-V (2001)

941 -V

Payment Voucher

OMB No. 1545-0074

Department of the Treasury Internal Revenue Service (99)

Do not staple or attach this voucher to your payment.

001

1Enter the first four letters of your last name (business name if corporation or partnership)

 2 Enter your employer identification number

3 Enter the amount of the payment

$

4 Tax period

5 Enter your business name (individual name if sole proprietor)

Enter your address

Enter your city, state, and ZIP code

1st
Quarter	3rd
Quarter	
2nd
Quarter	4th
Quarter	

Form 941 (Rev. 1-2001)

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, including income tax withholding. 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 employer identification number (EIN). Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia for use in administering their tax laws. If you fail to provide this information in a timely manner, you may be subject to penalties and interest.

The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is:

For Form 941:

Recordkeeping

	

11 hr., 44 min.

Learning about the law or the form Preparing the form

40 min.

	

1 hr., 49 min.

Copying, assembling, and sending the form to the IRS

	

16 min.

For Form 941TeleFile: Recordkeeping

	

5 hr., 1 min.

Learning about the law or the Tax

Record

	

6 min.

Preparing the Tax Record TeleFile phone call

	

11 min.

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.

	

11 min.

If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can write to the Tax Forms Committee, Western

Area Distribution Center, Rancho Cordova, CA

95743-0001. Do not send the tax form to this address.