OMB No. 1545-0256 Supporting Statement To Correct Information Form 941c

(Rev. October 2003)

 File with Forms 941, 941-M, 941-SS, 943, 945, or Form 843.

Page

No. Department of the Treasury

Internal Revenue Service

Name Employer identification number

Telephone number (optional) This form supports adjustments to: Check only one box. (see instructions)

Form 941 Form 945

Form 941-M

Enter the date that you discovered the error(s) reported on this form.

(If you are making more than one correction and the errors were not

discovered at the same time, explain in Part V.) 

This form is attached to and filed with the return for the

period ending (month, year) 

Signature and Certification (You must complete this part for the IRS to process your adjustments for

overpayments.) Skip Part I if all of your adjustments are underpayments. (Part I applies to wages only.)

I certify that Forms W-2c, Corrected Wage and Tax Statement, have been filed (as necessary) with the Social Security

Administration, and that (check appropriate boxes):

All overcollected income taxes for the current calendar year and all social security and Medicare taxes for the current and

prior calendar years have been repaid to employees. For claims of overcollected employee social security and Medicare

taxes in earlier years, a written statement has been obtained from each employee stating that the employee has not

claimed and will not claim refund or credit of the amount of the overcollection.

All affected employees have given their written consent to the allowance of this credit or refund. For claims of

overcollected employee social security and Medicare taxes in earlier years, a written statement has been obtained from

each employee stating that the employee has not claimed and will not claim refund or credit of the amount of the

overcollection.

The social security tax and Medicare tax adjustments represent the employer’s share only. An attempt was made to

locate the employee(s) affected, but the affected employee(s) could not be located or will not comply with the certification

requirements.

None of this refund or credit was withheld from employee wages.

Sign

Here Signature  Title  Date 

Income Tax Withholding (Including Backup Withholding) Adjustment

(a)

Period Corrected (For quarterly

returns, enter date quarter ended.

For annual returns, enter year.)

(c)

Correct Withheld

Income Tax for

Period

(b)

Withheld Income Tax

Previously Reported

for Period

(d)

Withheld Income

Tax Adjustment

1

2

3

4

5 Net withheld income tax adjustment. If more than one page, enter total of all columns (d) on first

page only. Enter here and on the appropriate line of the return with which you file this form.  5

Social Security Tax Adjustment (Use the tax rate in effect during the period(s) corrected. You must also

complete Part IV.)

(f)

Social Security Tax

Adjustment

(e)

Correct Tips for

Period

(d)

Tips Previously

Reported for Period

(c)

Correct Wages for

Period

(b)

Wages Previously

Reported for Period

(a)

Period Corrected (For quarterly

returns, enter date quarter ended.

For annual returns, enter year.)

1

2

3

4

5 Totals. If more than one page,

enter totals on first page only 

Net social security tax adjustment. If more than one page, enter total of all columns (f) on first

page only. Enter here and on the appropriate line of the return with which you file this form 

6

6

7 Net wage adjustment. If more than one page, enter total of all lines 7 on first page only. If line 5(c)

is smaller than line 5(b), enter difference in parentheses  7

8 Net tip adjustment. If more than one page, enter total of all lines 8 on first page only. If line 5(e)

is smaller than line 5(d), enter difference in parentheses  8

For Paperwork Reduction Act Notice, see page 4. Form 941c (Rev. 10-2003)

Part I

Part II

Part III

Do Not File Separately

A

B C

Cat. No. 11242O

Form 941-SS

Form 943
Form 941c (Rev. 10-2003) Page 2

Medicare Tax Adjustment

(d)

Medicare Tax

Adjustment

(a)

Period Corrected (For quarterly

returns, enter date quarter ended.

For annual returns, enter year.)

(c)

Correct Wages

and Tips for

Period

(b)

Wages and Tips

Previously Reported

for Period

1

2

3

4

5 Totals. If more than one page, enter totals on first page only 

6 Net Medicare tax adjustment. If more than one page, enter total of all columns (d) on first page

only. Enter here and on the appropriate line of the return with which you file this form  6

7 Net wage and tip adjustment. If more than one page, enter total of all lines 7 on first page only.

If line 5(c) is smaller than line 5(b), enter difference in parentheses  7

Part V Explanation of Adjustments

Part IV
Form 941c (Rev. 10-2003) Page 3

Specific Instructions

Purpose of form. Use Form 941c to provide

background information and certifications supporting

prior period adjustments to income, social security,

and Medicare taxes reported on Form 941, 941-M,

941-SS, 943, or 945. File it with the tax return on

which you are claiming the adjustment (Form 941, 943,

945, etc.). You may use Form 941c even though you

filed the original return on magnetic media or

electronically.

Complete all applicable columns on the line for each

return period that you are correcting. Show the total

amount paid to all employees, not the amount for each

individual employee. If you need more space, use

additional Forms 941c. If you use additional Forms

941c as continuation pages, be sure that the total and

net adjustment lines on the first form include the totals

from the continuation pages. These lines are line 5 of

Part II, lines 5 through 8 of Part III, and lines 5 through

7 of Part IV.

How to use Form 941c. Form 941c is not an

amended return and must never be filed separately.

You must make adjustments on the return (e.g., Form

941) for the period during which you discovered the

error. There is no limit to the number of adjustments

that you can make, and these adjustments can be for

corrections to more than one prior period. However, if

you filed two or more types of tax returns that need

correction (for example, Form 941 and Form 943), use

a separate Form 941c for each type of return. The net

adjustment increases or decreases your tax liability for

the period in which the error was discovered and

adjusted.

If your adjustment(s) results in an overpayment, you

may apply for a refund using Form 843, Claim for

Refund and Request for Abatement, instead of making

an adjustment as discussed above. If you choose to

file Form 843, you will receive a refund check (with

interest) instead of reducing your current employment

tax liability (no interest). When filing Form 843, attach

Form 941c or an equivalent statement.

Statute of limitations. Generally, you may make an

adjustment only within three years of the return due

date or the date the return was filed, whichever is later.

For purposes of the statute of limitations, the due date

of Forms 941, 941-M, 941-SS, 943, and 945 is April 15

of the year after the close of the tax year. For example,

the four quarterly Forms 941 filed for 2001 are all

treated as due on April 15, 2002. If they were filed on

or before April 15, 2002, adjustments could be made

for any of the quarterly returns for 2001 until April 15,

2005.

Line A. Check the box for the return that you are

adjusting. Check only one box. Use a separate

Form 941c for each type of return (e.g., Form 941 and

Form 945).

Line B. Show the return period in which you are

reporting tax adjustment(s). For example, if you are

making an adjustment on Form 941 for the quarter

ending June 30, 2003, enter 06-2003. File Form 941c

with the return for this period. Do not show the return

period(s) being corrected in this entry space.

Line C. Enter the date that you discovered the

error(s). If you are making more than one correction

and the errors were not discovered at the same time,

leave line C blank and explain in Part V. The date that

you discover the error(s) is the date that your tax

liability increases or decreases. Your deposits for this

date must be adjusted accordingly. See the related

return instructions for more information.

If you did not file a return for one or more return

periods, do not use Form 941c to report the

information. Instead, file the required returns.

Corrections not required. You are not required to

correct errors previously reported on the Summary of

Federal Tax Liability (e.g., line 17, Form 941, or line 15,

Form 943) or on Schedule B (Form 941), Form 943-A

or Form 945-A. Also, you are not required to correct

amounts previously reported on lines 1 or 2 of

Form 941 or Form 941-M; or line 1 of Form 941-SS or

Form 943.

Income tax withholding errors. Generally, you are not

permitted to correct income tax withholding errors

made in a prior calendar year. However, you may

make an adjustment to correct an administrative error

in a prior year. Refer to Circular E (Pub. 15),

Employer’s Tax Guide, for more information on

correcting administrative errors.

General Instructions

More information. See Circular E (Pub. 15), Circular A

(Pub. 51), Agricultural Employer’s Tax Guide, or your

form instructions for more information about

adjustments.

Part I—Signature and certification. Part I applies to

wages only. If any adjustment is for an overpayment, it

cannot be processed unless you check at least one

box in Part I and you sign the certification. If you

obtained written consents or statements from some

employees but you could not locate or secure the

cooperation of the remaining employees, check both

the second and third boxes. Provide a summary in

Part V of the amount of the adjustments for both the

employees who provided statements and for those

who did not.

You may make an adjustment for both the employer

and employee shares of social security and Medicare

taxes for those employees who provided the required

written statement. But you may make adjustments for

only the employer’s share for those employees who did

not provide statements.

Do not use Form 941c as a supporting statement for

current period adjustments (e.g., adjustment for

uncollected employee share of social security and

Medicare taxes on tips). No supporting statement is

required for the fractions-of-cents and third-party

sick pay adjustments. See your form instructions.
Form 941c (Rev. 10-2003) Page 4

Part III—Social security tax adjustment. Use this

part to correct social security wages and tips

information that you reported in an earlier period. You

may make corrections to social security taxes reported

in prior calendar years as long as the statute of

limitations has not expired (see Statute of limitations

on page 3). If you are reducing social security taxes,

be sure to read and check the appropriate boxes in

Part I.

Because Form W-2 is used by the Social Security

Administration (SSA) to post an employee’s social

security wages and tips to his or her earnings record,

you must file a Form W-2c, Corrected Wage and Tax

Statement, with the SSA and give copies to the

Part IV—Medicare tax adjustment. Use this part to

correct Medicare wages and tips information that you

reported in an earlier period. You may make

corrections to Medicare taxes reported in prior

calendar years as long as the statute of limitations has

not expired (see Statute of limitations on page 3). If

you are reducing Medicare taxes, be sure to read and

check the appropriate boxes in Part I.

You must file a Form W-2c with the SSA and give

copies to the employee for any Medicare correction

made after you filed Form W-2 with the SSA.

Paperwork Reduction Act Notice. We ask for the

information on this form to carry out the Internal

Revenue laws of the United States. You are required to

give us the information. We need it to ensure that you

are complying with these laws and to allow us to figure

and collect the right amount of tax.

The time needed to complete and file this form will

vary depending on individual circumstances. The

estimated average time is 9 hours and 12 minutes.

If you have comments concerning the accuracy of

this time estimate or suggestions for making this form

simpler, we would be happy to hear from you. You can

write to the IRS at the address shown in the Privacy

Act and Paperwork Reduction Act Notice in the

instructions of the tax return with which you file this

form.

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 or 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 Code

section 6103.

Part II—Income tax withholding (including backup

withholding) adjustment. Use this part to correct

income tax withholding (including backup withholding)

information that you previously reported. Show the

total amount of tax withheld, not the amount withheld

from each individual.

After the end of the year, you cannot adjust the

amounts reported as income tax withheld (including

backup withholding) unless it is to correct an

administrative error. An administrative error is any

error that does not change the amount of income tax

that was actually withheld. For example, if the total

income tax actually withheld was incorrectly reported

due to a mathematical computation or transposition

error, this is an administrative error.

Except to correct an administrative error, you will not

be allowed a refund or credit for any prior year

overpayment of income tax withheld (including backup

withholding). This is because the amount of

withholding shown on Form W-2, Wage and Tax

Statement, Form W-2G, Certain Gambling Winnings,

or Form 1099, is used as a credit on the employee’s or

income recipient’s income tax return (Form 1040, etc.).

If you are making an administrative error adjustment for

a period during a prior calendar year, provide an

explanation in Part V.

employee for any social security correction made after

you filed his or her Form W-2 with the SSA. Do not

send Form 941c (or a copy) to the SSA with

Form(s) W-2c.