Schedule D (Form 941):

Report of Discrepancies Caused by Acquisitions, Statutory Mergers, or Consolidations

(Rev. June 2011) Department of the Treasury—Internal Revenue Service

OMB No. 1545-0029

Employer Identification Number (EIN) —

Name (not your trade name)

Trade name (if any)

Address

Number Street Suite or room number

City State ZIP code

Phone number

Tax Year of Discrepancies (Fill in)

Format: YYYY

Type of Submission (Check one)

Original

Corrected

About this schedule

Each year the Internal Revenue Service (IRS) and the Social Security Administration (SSA) compare the totals on your Forms 941, 

Employer’s QUARTERLY Federal Tax Return, with the totals on Forms W-2, Wage and Tax Statement, to verify that:

• The wages you reported on Forms 941 match those you reported on Forms W-2 (Copy A) so that your 

employees’ social security earnings records are complete for benefit purposes; and

• You have paid the appropriate taxes.

Generally, the totals on your Forms W-2 (Copy A) should equal the totals you reported on Forms 941. Use this schedule if discrepancies 

exist between the totals you reported on those forms ONLY as a result of an acquisition, statutory merger, or consolidation. In many cases, 

the information on this schedule should help the IRS resolve discrepancies without contacting you. If you are an eligible employer 

who elects to use the alternate procedure set forth in Rev. Proc. 2004-53, explained in the instructions, you should file this schedule.

Read the separate instructions before you fill out this schedule.

Part 1: Answer these background questions.

1. Are you filing this schedule —

After a statutory merger or consolidation? (See Rev. Rul. 62-60, 1962-1 C.B. 186 and Rev. Proc. 2004-53, 2004-2 C.B. 320.)

You are either: An acquired corporation or

A surviving corporation. OR

After an acquisition and you are using the alternate procedure under Rev. Proc. 2004-53, 2004-2 C.B. 320?

You are either: A predecessor or

A successor.

2. The effective date of the statutory merger/consolidation or acquisition is . . . . . . . . .

MM / DD / YYYY

3. The OTHER PARTY in this transaction is . . .

Other party’s EIN —

Other party’s name

Trade name (if any)

Address

Number Street Suite or room number

City State ZIP code

Phone number Next ■▶

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 38791Y Schedule D (Form 941) (Rev. 6-2011)
Your EIN —

Name (not your trade name)

Other party’s EIN —

Tax Year of Discrepancies (Fill in)

Format: YYYY

Part 2: Tell us about the discrepancies with your returns.

Column A

Amount you reported to IRS 

for the tax year

Totals from Forms 941 as corrected 

by any Forms 941-X

–

Column B

Amount you reported to SSA 

for the tax year

Totals from Forms W-2 (Copy A) as 

corrected by any Forms W-2c (Copy A)

=

Column C

The difference

4. Social security wages – =

5. Medicare wages and tips – =

6. Social security tips – =

7. Federal income tax 

withheld – =

8. Advance earned income credit 

(EIC) payments (for tax years 

ending before January 1, 2011)

– =

If you are filing for one transaction only, STOP here. If you are filing for more than one transaction, go to Part 3.

Part 3: Fill this part out ONLY if you are filing more than one Schedule D (Form 941) for any calendar year.

9. File one Schedule D (Form 941) for each separate transaction. This is schedule of . (Example: This is schedule 1 of 3.)

Column A

Amount you reported to IRS 

for the tax year for the 

employees affected by the 

transaction reported on this 

Schedule D (Form 941)

Totals from Forms 941 as corrected 

by any Forms 941-X

–

Column B

Amount you reported to SSA 

for the tax year for the 

employees affected by the 

transaction reported on this 

Schedule D (Form 941)

Totals from Forms W-2 (Copy A) as 

corrected by any Forms W-2c (Copy A)

=

Column C

The difference

10. Social security wages – =

11. Medicare wages and tips – =

12. Social security tips – =

13. Federal income tax 

withheld – =

14. Advance earned income credit 

(EIC) payments (for tax years 

ending before January 1, 2011)

– =

Page 2 Schedule D (Form 941) (Rev. 6-2011)