Form 941-SS for 2012:

(Rev. January 2012)

Department of the Treasury — Internal Revenue Service

Employer’s QUARTERLY Federal Tax Return

American Samoa, Guam, the Commonwealth of the Northern 

Mariana Islands, and the U.S. Virgin Islands OMB No. 1545-0029

(EIN) 

Employer identification number —

Name (not your trade name)

Trade name (if any)

Address

Number Street Suite or room number

City State ZIP code

Report for this Quarter of 2012 

(Check one.)

1: January, February, March

2: April, May, June

3: July, August, September

4: October, November, December

Prior-year forms are available at 

www.irs.gov/form941ss.

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

Part 1: Answer these questions for this quarter.

1 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

2

3

4 If no wages, tips, and other compensation are subject to social security or Medicare tax Check and go to line 6.

Column 1 Column 2

5a Taxable social security wages . × .104 = .

5b Taxable social security tips . × .104 = .

5c Taxable Medicare wages & tips . × .029 = .

5d Add Column 2 line 5a, Column 2 line 5b, and Column 2 line 5c . . . . . . . . . . 5d .

5e Section 3121(q) Notice and Demand—Tax due on unreported tips (see instructions) . . . . 5e .

6 Total taxes before adjustments (add lines 5d and 5e) . . . . . . . . . . . . . . 6 .

7 Current quarter’s adjustment for fractions of cents . . . . . . . . . . . . . . 7 .

8 Current quarter’s adjustment for sick pay . . . . . . . . . . . . . . . . . 8 .

9 Current quarter’s adjustments for tips and group-term life insurance . . . . . . . . 9 .

10 Total taxes after adjustments. Combine lines 6 through 9 . . . . . . . . . . . . 10 .

11 Total deposits for this quarter, including overpayment applied from a prior quarter and 

overpayment applied from Form 941-X or Form 944-X . . . . . . . . . . . . . 11 .

12a COBRA premium assistance payments (see instructions) . . . . . . . . . . . . 12a .

12b Number of individuals provided COBRA premium assistance . . .

13 Add lines 11 and 12a . . . . . . . . . . . . . . . . . . . . . . . . 13 .

14 Balance due. If line 10 is more than line 13, enter difference and see instructions . . . . . 14 .

15 Overpayment. If line 13 is more than line 10, enter difference . Check one: Apply to next return. Send a refund.

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

Next ■▶

For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher. Cat. No. 17016Y Form 941-SS (Rev. 1-2012)
Name (not your trade name) Employer identification number (EIN)

Part 2: 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. 80 

(Circular SS), section 8. 

16 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: 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-SS.

Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank.

17 If your business has closed or you stopped paying wages . . . . . . . . . . . . . . . . Check here, and

enter the final date you paid wages .

18 If you are a seasonal employer and you do not have to file a return for every quarter of the year . . . Check here.

Part 4: 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 IRS.

No.

Part 5: Sign here. You MUST complete both pages of Form 941-SS 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.

✗ Sign your 

name here

Date

Print your 

name here

Print your 

title here

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 State ZIP code

Page 2 Form 941-SS (Rev. 1-2012)
Form 941-V(SS), 

Payment Voucher

Purpose of Form

Complete Form 941-V(SS), Payment Voucher, if you 

are making a payment with Form 941-SS, Employer’s 

QUARTERLY Federal Tax Return. We will use the 

completed voucher to credit your payment more 

promptly and accurately, and to improve our service to 

you.

If you have your return prepared by a third party and 

make a payment with that return, please provide this 

payment voucher to the return preparer.

Making Payments With Form 941-SS

To avoid a penalty, make your payment with Form 

941-SS only if:

• Your net taxes for either the current quarter or the 

preceding quarter (line 10) on Form 941-SS are less than 

$2,500, you did not incur a $100,000 next-day deposit 

obligation during the current quarter, and you are paying 

in full with a timely filed return, or

• You are a monthly schedule depositor making a 

payment in accordance with the Accuracy of Deposits 

Rule. See section 8 of Pub. 80 (Circular SS), Federal 

Tax Guide for Employers in the U.S. Virgin Islands, Guam, 

American Samoa, and the Commonwealth of the 

Northern Mariana Islands, for details. In this case, the 

amount of your payment may be $2,500 or more.

Otherwise, you must make deposits by electronic funds 

transfer. See section 8 of Pub. 80 (Circular SS) for deposit 

instructions. Do not use Form 941-V(SS) to make federal 

tax deposits.

Caution. Use Form 941-V(SS) when making any

payment with Form 941-SS. However, if you pay an

amount with Form 941-SS that should have been

deposited, you may be subject to a penalty. See

Deposit Penalties in section 8 of Pub. 80 (Circular SS).

Specific Instructions

Box 1—Employer identification number (EIN). If you

do not have an EIN, you may apply for one online. Go to 

IRS.gov and click on the Apply for an EIN Online link. You 

may also apply for an EIN by calling 1-800-829-4933, or 

you can fax or mail Form SS-4, Application for Employer 

Identification Number. If you have not received your EIN 

by the due date of Form 941-SS, write “Applied For” and 

the date you applied in this entry space.

Box 2—Amount paid. Enter the amount paid with

Form 941-SS.

Box 3—Tax period. Darken the circle identifying the

quarter for which the payment is made. Darken only

one circle.

Box 4—Name and address. Enter your name and

address as shown on Form 941-SS.

• Enclose your check or money order payable to the 

“United States Treasury.” Be sure to enter your EIN, 

“Form 941-SS,” and the tax period on your check or 

money order. Do not send cash. Do not staple Form 

941-V(SS) or your payment to Form 941-SS (or to each 

other).

• Detach Form 941-V(SS) and send it with your 

payment and Form 941-SS to the address in the 

Instructions for Form 941-SS.

Note. You must also complete the entity information

above Part 1 on Form 941-SS.

✁ ▼ Detach Here and Mail With Your Payment and Form 941-SS. ▼

✃

Form 941-V(SS)

Department of the Treasury 

Internal Revenue Service

Payment Voucher

▶ Do not staple this voucher or your payment to Form 941-SS.

OMB No. 1545-0029

2012

1 Enter your employer identification 

number (EIN).

2

Enter the amount of your payment. ▶

Dollars Cents

3 Tax period

1st 

Quarter

2nd 

Quarter

3rd 

Quarter

4th 

Quarter

4 Enter your business name (individual name if sole proprietor).

Enter your address.

Enter your city, state, and ZIP code.
Form 941-SS (Rev. 1-2012)

Privacy Act and Paperwork Reduction Act Notice. 

We ask for the information on Form 941-SS 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, including 

income tax withholding. Form 941-SS is used to 

determine the amount of the 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 

and interest.

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 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-SS 

will vary depending on individual circumstances. The 

estimated average time is:

Recordkeeping . . . . . . . . . 10 hrs., 31 min.

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-SS simpler, we would be happy to hear from you. 

You can email us at taxforms@irs.gov. Enter “Form 

941-SS” on the subject line. Or write to: Internal Revenue 

Service, Tax Products Coordinating Committee, 

SE:W:CAR:MP:T:M:S, 1111 Constitution Ave. NW, 

IR-6526, Washington, DC 20224. Do not send Form 

941-SS to this address. Instead, see Where Should 

You File? in the Instructions for Form 941-SS.