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26 U.S.C. § 7201
Sole Proprietorship or Partnership
Employer's Quarterly Return
Attempt to Evade and Defeat
Federal Withholding and F.I.C.A. (Social Security Taxes)IN THE DISTRICT COURT OF THE UNITED STATES FOR THE _____________ DISTRICT OF ____________
UNITED STATES OF AMERICA
v.
_______________________
)
)
)
)
)No. __________________
26 U.S.C., § 7201The grand jury charges:
That on or about the _________ day of _______________, 19___, in the _________________ District of _______________, [Defendant's Name], a resident of [City], [State], who conducted a business1 as a [Sole Proprietorship or Partnership] under the name and style of _____________, with its principal place of business in [City], [State], did willfully attempt to evade and defeat a large part of the federal income taxes withheld from wages and Federal Insurance Contributions Act taxes due and owing to the United States of America for the quarter ending __________, 19___, by preparing and causing to be prepared, and by signing and causing to be signed,2 a false and fraudulent Employer's Quarterly Federal Tax Return, Form 941, which was filed with the Internal Revenue Service, wherein it was stated that the total wages subject to withholding paid to employees by [Name of Business] for the said quarter was the sum of $_________, and that the total amount of federal income tax withheld and social security taxes due and owing thereon was the sum of $_________, whereas, as he [she] [it] then and there well knew and believed, the total wages subject to withholding paid to employees for said quarter was the sum of $_________, upon which wages there were due and owing to the United States of America federal income taxes withheld from wages and social security taxes in the total amount of $_________.
In violation of Title 26, United States Code, Section 7201.
A True Bill.
_________________________
Foreperson_________________________
United States Attorney
NOTES1. If employer is a corporation, refer to Forms - 25 as a guide in charging appropriate corporate officials with attempting to evade and defeat taxes due from corporation.
2. If venue is to be placed in judicial district in which the return was filed, modify this form in accordance with language at Forms - 3 and related Footnote 2. If venue is based on mailing, substitute "by mailing and causing to be mailed".
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Uploaded April 1998
