Forms 941, Employer's Quarterly Federal Tax Return; American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, and the U.S. Virgin Islands

Version A, Cycle 10
Fillable Fields: Font=10pt Times; Color=Black; Checkmark=Cross

941 for 2014:

Form
(Rev. January 2014)

Employer’s QUARTERLY Federal Tax Return

950114
OMB No. 1545-0029

Department of the Treasury — Internal Revenue Service

Report for this Quarter of 2014

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Employer identification number (EIN)

(Check one.)

1: January, February, March

Name (not your trade name)

2: April, May, June

Trade name (if any)

3: July, August, September
4: October, November, December

Address
Number

Street

Suite or room number

City

State

Foreign country name

Instructions and prior year forms are
available at www.irs.gov/form941.

ZIP code

Foreign postal code

Foreign province/county

Read the separate instructions before you complete Form 941. Type or print within the boxes.

Part 1:
1

Answer these questions for this quarter.

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)

1

For Internal Testing
Purposes Only
DRAFT AS OF
June 25, 2013

2

Wages, tips, and other compensation

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2

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Federal income tax withheld from wages, tips, and other compensation .

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3

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If no wages, tips, and other compensation are subject to social security or Medicare tax

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Column 1

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Column 2

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5a

Taxable social security wages .

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5b

Taxable social security tips .

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5c

Taxable Medicare wages & tips .

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5d

Taxable wages & tips subject to
Additional Medicare Tax withholding

5e

Add Column 2 from lines 5a, 5b, 5c, and 5d

5f

Section 3121(q) Notice and Demand—Tax due on unreported tips (see instructions)

6

Total taxes before adjustments. Add lines 3, 5e, and 5f .

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7

Current quarter’s adjustment for fractions of cents .

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8

Current quarter’s adjustment for sick pay .

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9

Current quarter’s adjustments for tips and group-term life insurance

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× .124 =
× .124 =
× .029 =
× .009 =

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Check and go to line 6.

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5e

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5f

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6

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7

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8

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9

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10

Total taxes after adjustments. Combine lines 6 through 9

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11

Total deposits for this quarter, including overpayment applied from a prior quarter and
overpayments applied from Form 941-X, 941-X (PR), 944-X, 944-X (PR), or 944-X (SP) filed
in the current quarter . . . . . . . . . . . . . . . . . . . . . . .

11

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Balance due. If line 10 is more than line 11, enter the difference and see instructions

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Overpayment. If line 11 is more than line 10, enter the difference

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Check one:

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Apply to next return.

Send a refund.

Next ■▶

You MUST complete both pages of Form 941 and SIGN it.

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

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Cat. No. 17001Z

Form 941 (Rev. 1-2014)

Version A, Cycle 10

950214
Name (not your trade name)

Part 2:

Employer identification number (EIN)

Tell us about your deposit schedule and tax liability for this quarter.

If you are unsure about whether you are a monthly schedule depositor or a semiweekly schedule depositor, see Pub. 15
(Circular E), section 11.
14 Check one:

Line 10 on this return is less than $2,500 or line 10 on the return for the prior quarter was less than $2,500, and you did not incur a
$100,000 next-day deposit obligation during the current quarter. If line 10 for the prior quarter was less than $2,500 but line 10 on this return
is $100,000 or more, you must provide a record of your federal tax liability. If you are a monthly schedule depositor, complete the deposit
schedule below; if you are a semiweekly schedule depositor, attach Schedule B (Form 941). Go to Part 3.

You were a monthly schedule depositor for the entire quarter. Enter your tax liability for each month and total
liability for the quarter, then go to Part 3.
Tax liability:

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Month 1
Month 2
Month 3

Total liability for quarter

Total must equal line 10.

You were a semiweekly schedule depositor for any part of this quarter. Complete Schedule B (Form 941),
Report of Tax Liability for Semiweekly Schedule Depositors, and attach it to Form 941.

Part 3:

For Internal Testing
Purposes Only
DRAFT AS OF
June 25, 2013

Tell us about your business. If a question does NOT apply to your business, leave it blank.

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

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Check here, and

16 If you are a seasonal employer and you do not have to file a return for every quarter of the year

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Check here.

enter the final date you paid wages

Part 4:

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May we speak with your third-party designee?

Do you want to allow an employee, a paid tax preparer, or another person to discuss this return with the IRS? See the instructions
for details.

Yes. Designee’s name and phone number

Select a 5-digit Personal Identification Number (PIN) to use when talking to the IRS.

No.

Part 5:

Sign here. You MUST complete both pages of Form 941 and SIGN it.

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. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

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Print your
name here

Sign your
name here

Date

Print your
title here
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Best daytime phone

Paid Preparer Use Only

Check if you are self-employed

Preparer’s name

PTIN

Preparer’s signature

Date

Firm’s name (or yours
if self-employed)

EIN

Address

Phone

City
Page 2

State

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ZIP code
Form 941 (Rev. 1-2014)

Version A, Cycle 10
Form 941 (Rev. 1-2014)

Privacy Act and Paperwork Reduction Act Notice.
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. Subtitle C,
Employment Taxes, of the Internal Revenue Code
imposes employment taxes on wages and provides for
income tax withholding. Form 941 is used to determine
the amount of 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 identification number. If you fail to provide this
information in a timely manner, or provide false or
fraudulent information, you may be subject to penalties.
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
its 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. However,
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. For example, we may
disclose your tax information to the Department of

Justice for civil and criminal litigation, and to cities,
states, the District of Columbia, and U.S. commonwealths
and possessions for use in administering their tax laws.
We may also disclose this information to other countries
under a tax treaty, to federal and state agencies to
enforce federal nontax criminal laws, or to federal law
enforcement and intelligence agencies to combat
terrorism.
The time needed to complete and file Form 941 will
vary depending on individual circumstances. The
estimated average time is:
Recordkeeping . . . . . . . . . . . . . 11 hr.
Learning about the law or the form . . . . 47 min.
Preparing, copying, assembling, and
sending the form to the IRS . . . . . . . . 1 hr.
If you have comments concerning the accuracy of
these time estimates or suggestions for making Form 941
simpler, we would be happy to hear from you. You can
send us comments from www.irs.gov/formspubs. Click on
More Information and then click on Comment on Tax
Forms and Publications. Or you can send your comments
to Internal Revenue Service, Tax Forms and Publications
Division, 1111 Constitution Ave. NW, IR-6526,
Washington, DC 20224. Do not send Form 941 to this
address. Instead, see Where Should You File? in the
Instructions for Form 941.

For Internal Testing
Purposes Only
DRAFT AS OF
June 25, 2013