For the quarter ending:

March 31 June 30 September 30 December 31

Part 1: Answer These Questions for This Quarter

1. Number of employees who received wages, tips, or other compensation: 2. Total wages, tips, and other compensation: 3. Federal income tax withheld from wages, tips, and other compensation: 4. If no wages, tips, and other compensation are subject to Social Security or Medicare tax:

Part 2: Determine Taxable Social Security and Medicare Wages and Tips

5a. Taxable Social Security wages: 5b. Taxable Social Security tips: 5c. Taxable Medicare wages & tips: 5d. Taxable wages & tips subject to Additional Medicare Tax withholding:

Part 3: Calculate the Employer's Portion of Social Security and Medicare Taxes

6. Total Social Security and Medicare taxes:

Part 4: Calculate Deposits and Balance Due or Overpayment

7. Total taxes before adjustments: 8. Current quarter’s adjustment for fractions of cents: 9. Current quarter’s adjustment for sick pay: 10. Current quarter’s adjustments for tips and group-term life insurance: 11. Total taxes after adjustments: 12. Total deposits for this quarter, including overpayment applied from prior quarter: 13. Balance due: 14. Overpayment:

Part 5: Report Your Tax Liability for the Quarter

Note: Employers must fill out Schedule B (Form 941) if they are semiweekly schedule depositors.

Part 6: May We Speak with Your Third-Party Designee?

Yes No

Part 7: Sign Here

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.

Employer’s signature: Date: Title: Best daytime phone number:

941 form generator

Form 941: Employer's Quarterly Federal Tax Return