Tax Year *

Employer

* Employer identification number (EIN) * Name (not your trade name) Trade name (if any) Country Address (number and street) Apt / Ste no. City State ZIP code

Foreign province/county Foreign postal code

* Report for this quarter 1: January, February, March 2: April, May, June 3: July, August, September 4: October, November, December

Part 1 — Wages and taxes

1. Number of employees who received wages, tips, or other compensation 2. 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 5a. Taxable social security wages 5a(i). Qualified sick leave wages (COVID-era years) 5a(ii). Qualified family leave wages (COVID-era years) 5b. Taxable social security tips 5c. Taxable Medicare wages & tips 5d. Taxable wages & tips subject to Additional Medicare Tax withholding 5e. Total social security and Medicare taxes 5f. Section 3121(q) Notice and Demand — Tax due on unreported tips 6. Total taxes before adjustments 7. Current quarter’s adjustment for fractions of cents 8. Current quarter’s adjustment for sick pay 9. Current quarter’s adjustments for tips and group-term life insurance 10. Total taxes after adjustments 11. Qualified small business payroll tax credit for increasing research activities 12. Total taxes after adjustments and nonrefundable credits 13. Total deposits for this quarter 14. Balance due 15. Overpayment

If line 15 is overpayment, apply or refund? Apply to next return Send a refund

15c. Routing number

15d. Account type Checking Savings

15e. Account number

Part 2 — Deposit schedule and tax liability

16. Deposit schedule Line 12 is less than $2,500 Monthly schedule depositor Semiweekly schedule depositor (attach Schedule B)

Enter your tax liability for each month, not your deposits.

Month 1 tax liability Month 2 tax liability Month 3 tax liability Total liability for quarter

Part 3 — Business questions

17. If your business has closed or you stopped paying wages

Date you last paid wages

18. If you are a seasonal employer and you don’t have to file a return for every quarter of the year

COVID-era lines (shown for 2020–2023)

19. Qualified health plan expenses allocable to qualified sick leave wages 20. Qualified health plan expenses allocable to qualified family leave wages 21. Qualified wages for the employee retention credit 22. Qualified health plan expenses for the employee retention credit 23. Credit from Form 5884-C 24. Qualified sick leave wages for leave taken after March 31, 2021 25. Qualified health plan expenses allocable to those sick leave wages 26. Qualified family leave wages for leave taken after March 31, 2021 27. Qualified health plan expenses allocable to those family leave wages 28. Other COVID-era amount

Part 4 — Third-party designee

Do you want to allow another person to discuss this return with the IRS? Yes No

Designee’s name Phone 5-digit PIN

Part 5 — Sign here

Your signature

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Print your name

Date

Title Best daytime phone

Paid Preparer Use Only

Are you a paid preparer? Yes No

Preparer’s name Preparer’s signature

Date

PTIN Check if self-employed Firm’s name Firm’s EIN Firm’s address Firm city Firm state Firm ZIP Firm’s phone

Email Information

Email address for delivery *

Online Form 941 Form Generator

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