Form 941-X:

(Rev. July 2021)

Adjusted Employer’s QUARTERLY Federal Tax Return or Claim for Refund

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

Foreign country name Foreign province/county Foreign postal code

Read the separate instructions before completing this form. Use this form to correct errors you 

made on Form 941 or 941-SS. Use a separate Form 941-X for each quarter that needs 

correction. Type or print within the boxes. You MUST complete all five pages. Don’t attach this 

form to Form 941 or 941-SS unless you’re reclassifying workers; see the instructions for line 42.

Part 1: Select ONLY one process. See page 6 for additional guidance, including information 

on how to treat employment tax credits and social security tax deferrals.

1. Adjusted employment tax return. Check this box if you underreported tax amounts. 

Also check this box if you overreported tax amounts and you would like to use the 

adjustment process to correct the errors. You must check this box if you’re correcting 

both underreported and overreported tax amounts on this form. The amount shown on 

line 27, if less than zero, may only be applied as a credit to your Form 941, Form 941-SS, 

or Form 944 for the tax period in which you’re filing this form.

2. Claim. Check this box if you overreported tax amounts only and you would like to use 

the claim process to ask for a refund or abatement of the amount shown on line 27. 

Don’t check this box if you’re correcting ANY underreported tax amounts on this form.

Part 2: Complete the certifications.

3. I certify that I’ve filed or will file Forms W-2, Wage and Tax Statement, or Forms W-2c, Corrected Wage and Tax Statement, 

as required.

Note: If you’re correcting underreported tax amounts only, go to Part 3 on page 2 and skip lines 4 and 5. If you’re correcting overreported 

tax amounts, for purposes of the certifications on lines 4 and 5, Medicare tax doesn’t include Additional Medicare Tax. Form 941-X can’t be 

used to correct overreported amounts of Additional Medicare Tax unless the amounts weren’t withheld from employee wages or an 

adjustment is being made for the current year.

4. If you checked line 1 because you’re adjusting overreported federal income tax, social security tax, Medicare tax, or Additional 

Medicare Tax, check all that apply. You must check at least one box. 

I certify that:

a. I repaid or reimbursed each affected employee for the overcollected federal income tax or Additional Medicare Tax for the current 

year and the overcollected social security tax and Medicare tax for current and prior years. For adjustments of employee social 

security tax and Medicare tax overcollected in prior years, I have a written statement from each affected employee stating that he 

or she hasn’t claimed (or the claim was rejected) and won’t claim a refund or credit for the overcollection.

b. The adjustments of social security tax and Medicare tax are for the employer’s share only. I couldn’t find the affected employees or 

each affected employee didn’t give me a written statement that he or she hasn’t claimed (or the claim was rejected) and won’t 

claim a refund or credit for the overcollection.

c. The adjustment is for federal income tax, social security tax, Medicare tax, or Additional Medicare Tax that I didn’t withhold from 

employee wages.

5. If you checked line 2 because you’re claiming a refund or abatement of overreported federal income tax, social security tax, 

Medicare tax, or Additional Medicare Tax, check all that apply. You must check at least one box. 

I certify that:

a. I repaid or reimbursed each affected employee for the overcollected social security tax and Medicare tax. For claims of employee 

social security tax and Medicare tax overcollected in prior years, I have a written statement from each affected employee stating 

that he or she hasn’t claimed (or the claim was rejected) and won’t claim a refund or credit for the overcollection.

b. I have a written consent from each affected employee stating that I may file this claim for the employee’s share of social security 

tax and Medicare tax. For refunds of employee social security tax and Medicare tax overcollected in prior years, I also have a 

written statement from each affected employee stating that he or she hasn’t claimed (or the claim was rejected) and won’t claim a 

refund or credit for the overcollection.

c. The claim for social security tax and Medicare tax is for the employer’s share only. I couldn’t find the affected employees, or each 

affected employee didn’t give me a written consent to file a claim for the employee’s share of social security tax and Medicare tax, 

or each affected employee didn’t give me a written statement that he or she hasn’t claimed (or the claim was rejected) and won’t 

claim a refund or credit for the overcollection.

d. The claim is for federal income tax, social security tax, Medicare tax, or Additional Medicare Tax that I didn’t withhold from 

employee wages. Next ■▶

For Paperwork Reduction Act Notice, see the separate instructions. www.irs.gov/Form941X Cat. No. 17025J Form 941-X (Rev. 7-2021) 

Return You’re Correcting...

Check the type of return you’re correcting.

941

941-SS

Check the ONE quarter you’re correcting.

1: January, February, March

2: April, May, June

3: July, August, September

4: October, November, December

Enter the calendar year of the 

quarter you’re correcting.

(YYYY)

Enter the date you discovered errors.

/ /

(MM / DD / YYYY)
Name (not your trade name) Employer identification number (EIN) Correcting quarter (1, 2, 3, 4)

Correcting calendar year (YYYY)

Part 3: Enter the corrections for this quarter. If any line doesn’t apply, leave it blank.

Column 1

Total corrected 

amount (for ALL 

employees) —

Column 2

Amount originally 

reported or as 

previously corrected 

(for ALL employees) =

Column 3

Difference 

(If this amount is a 

negative number, 

use a minus sign.)

Column 4

Tax correction

6. Wages, tips, and other 

compensation (Form 941, line 2) . — . = . Use the amount in Column 1 when you 

prepare your Forms W-2 or Forms W-2c.

7. Federal income tax withheld 

from wages, tips, and other 

compensation (Form 941, line 3) . — . = . Copy Column 

3 here ▶ .

8. Taxable social security wages 

(Form 941 or 941-SS, line 5a, 

Column 1) . — . = . × 0.124* = .

* If you’re correcting your employer share only, use 0.062. See instructions.

9. Qualified sick leave wages* 

(Form 941 or 941-SS, line 5a(i), 

Column 1) . — . = . × 0.062 = .

* Use line 9 only for qualified sick leave wages paid after March 31, 2020, for leave taken before April 1, 2021.

10. Qualified family leave wages* 

(Form 941 or 941-SS, line 5a(ii), 

Column 1) . — . = . × 0.062 = .

* Use line 10 only for qualified family leave wages paid after March 31, 2020, for leave taken before April 1, 2021.

11. Taxable social security tips (Form 

941 or 941-SS, line 5b, Column 1) . — . = . × 0.124* = .

* If you’re correcting your employer share only, use 0.062. See instructions.

12. Taxable Medicare wages & tips (Form 

941 or 941-SS, line 5c, Column 1) . — . = . × 0.029* = .

* If you’re correcting your employer share only, use 0.0145. See instructions.

13. Taxable wages & tips subject to 

Additional Medicare Tax 

withholding (Form 941 or 

941-SS, line 5d)

. — . = . × 0.009* = .

* Certain wages and tips reported in Column 3 shouldn’t be multiplied by 0.009. See instructions.

14. Section 3121(q) Notice and 

Demand—Tax due on 

unreported tips (Form 941 or 

941-SS, line 5f)

. — . = . Copy Column 

3 here ▶ .

15. Tax adjustments (Form 941 or 

941-SS, lines 7 through 9) . — . = . Copy Column 

3 here ▶ .

16. Qualified small business payroll tax 

credit for increasing research 

activities (Form 941 or 941-SS, line 

11a; you must attach Form 8974)

. — . = . See 

instructions .

17. Nonrefundable portion of credit 

for qualified sick and family 

leave wages for leave taken 

before April 1, 2021 (Form 941 

or 941-SS, line 11b)

. — . = . See 

instructions .

18a. Nonrefundable portion of 

employee retention credit 

(Form 941 or 941-SS, line 11c) . — . = . See 

instructions .

18b. Nonrefundable portion of credit 

for qualified sick and family 

leave wages for leave taken 

after March 31, 2021 (Form 941 

or 941-SS, line 11d)

. — . = . See 

instructions .

18c. Nonrefundable portion of COBRA 

premium assistance credit 

(Form 941 or 941-SS, line 11e) . — . = . See 

instructions .

18d. Number of individuals provided 

COBRA premium assistance 

(Form 941 or 941-SS, line 11f)

— =

19. Special addition to wages for 

federal income tax . — . = . See 

instructions .

20. Special addition to wages for 

social security taxes . — . = . See 

instructions .

21. Special addition to wages for 

Medicare taxes . — . = . See 

instructions .

Next ■▶

Page 2 Form 941-X (Rev. 7-2021)
Name (not your trade name) Employer identification number (EIN) Correcting quarter (1, 2, 3, 4)

Correcting calendar year (YYYY)

Part 3: Enter the corrections for this quarter. If any line doesn’t apply, leave it blank. (continued)

Column 1

Total corrected 

amount (for ALL 

employees) —

Column 2

Amount originally 

reported or as 

previously corrected 

(for ALL employees) =

Column 3

Difference 

(If this amount is a 

negative number, 

use a minus sign.)

Column 4

Tax correction

22. Special addition to wages for 

Additional Medicare Tax . — . = . See 

instructions .

23. Combine the amounts on lines 7 through 22 of Column 4 . . . . . . . . . . . . . . . . . . . .

24. Deferred amount of social 

security tax* (Form 941 or 

941-SS, line 13b) . — . = . See 

instructions .

* Use this line to correct the employer deferral for the second quarter of 2020 and the employer and employee deferral for the third and fourth quarters of 2020.

25. Refundable portion of credit for 

qualified sick and family leave 

wages for leave taken before 

April 1, 2021 (Form 941 or 941-

SS, line 13c)

. — . = . See 

instructions .

26a. Refundable portion of employee 

retention credit (Form 941 or 

941-SS, line 13d)

. — . = . See 

instructions .

26b. Refundable portion of credit for 

qualified sick and family leave 

wages for leave taken after 

March 31, 2021 (Form 941 or 

941-SS, line 13e)

. — . = . See 

instructions .

26c. Refundable portion of COBRA 

premium assistance credit 

(Form 941 or 941-SS, line 13f)

. — . = . See 

instructions .

27. Total. Combine the amounts on lines 23 through 26c of Column 4 . . . . . . . . . . . . . . . . .

If line 27 is less than zero:

• If you checked line 1, this is the amount you want applied as a credit to your Form 941 or 941-SS for the tax period in which you’re 

filing this form. (If you’re currently filing a Form 944, Employer’s ANNUAL Federal Tax Return, see the instructions.)

• If you checked line 2, this is the amount you want refunded or abated.

If line 27 is more than zero, this is the amount you owe. Pay this amount by the time you file this return. For information on how to 

pay, see Amount you owe in the instructions.

28. Qualified health plan expenses 

allocable to qualified sick leave 

wages for leave taken before 

April 1, 2021 (Form 941 or 941-

SS, line 19)

. — . = .

29. Qualified health plan expenses 

allocable to qualified family 

leave wages for leave taken 

before April 1, 2021 (Form 941 or 

941-SS, line 20)

. — . = .

30. Qualified wages for the 

employee retention credit 

(Form 941 or 941-SS, line 21)

. — . = .

31a. Qualified health plan expenses 

for the employee retention credit 

(Form 941 or 941-SS, line 22)

. — . = .

31b. Check here if you’re eligible for the employee retention credit in the third or fourth quarter of 2021 

solely because your business is a recovery startup business . . . . . . . . . . . .

32. Credit from Form 5884-C, line 

11, for this quarter* (Form 941 or 

941-SS, line 23)

. — . = .

* Use line 32 to correct only the second, third, and fourth quarters of 2020, and the first quarter of 2021.

Next ■▶

Page 3 Form 941-X (Rev. 7-2021)
Name (not your trade name) Employer identification number (EIN) Correcting quarter (1, 2, 3, 4)

Correcting calendar year (YYYY)

Part 3: Enter the corrections for this quarter. If any line doesn’t apply, leave it blank. (continued)

Column 1

Total corrected 

amount (for ALL 

employees) —

Column 2

Amount originally 

reported or as 

previously corrected 

(for ALL employees) =

Column 3

Difference 

(If this amount is a 

negative number, 

use a minus sign.)

33a. Qualified wages paid March 13 

through March 31, 2020, for the 

employee retention credit* 

(Form 941 or 941-SS, line 24)

. — . = .

* Use line 33a to correct only the second quarter of 2020.

33b. Deferred amount of the 

employee share of social 

security tax included on Form 

941 or 941-SS, line 13b* 

(Form 941 or 941-SS, line 24)

. — . = .

* Use line 33b to correct only the third and fourth quarters of 2020.

34. Qualified health plan expenses 

allocable to wages reported on 

Form 941 or 941-SS, line 24* 

(Form 941 or 941-SS, line 25)

. — . = .

* Use line 34 to correct only the second quarter of 2020.

Caution: Lines 35–40 apply only to quarters beginning after March 31, 2021.

35. Qualified sick leave wages for 

leave taken after March 31, 2021 

(Form 941 or 941-SS, line 23)

. — . = .

36. Qualified health plan expenses 

allocable to qualified sick leave 

wages for leave taken after 

March 31, 2021 (Form 941 or 

941-SS, line 24)

. — . = .

37. Amounts under certain 

collectively bargained 

agreements allocable to 

qualified sick leave wages for 

leave taken after March 31, 

2021 (Form 941 or 941-SS, 

line 25)

. — . = .

38. Qualified family leave wages for 

leave taken after March 31, 2021 

(Form 941 or 941-SS, line 26)

. — . = .

39. Qualified health plan expenses 

allocable to qualified family 

leave wages for leave taken 

after March 31, 2021 (Form 941 

or 941-SS, line 27)

. — . = .

40. Amounts under certain 

collectively bargained 

agreements allocable to 

qualified family leave wages for 

leave taken after March 31, 2021 

(Form 941 or 941-SS, line 28)

. — . = .

Next ■▶

Page 4 Form 941-X (Rev. 7-2021)
Name (not your trade name) Employer identification number (EIN) Correcting quarter (1, 2, 3, 4)

Correcting calendar year (YYYY)

Part 4: Explain your corrections for this quarter.

41. Check here if any corrections you entered on a line include both underreported and overreported amounts. Explain both 

your underreported and overreported amounts on line 43.

42. Check here if any corrections involve reclassified workers. Explain on line 43.

43. You must give us a detailed explanation of how you determined your corrections. See the instructions.

Part 5: Sign here. You must complete all five pages of this form and sign it.

Under penalties of perjury, I declare that I have filed an original Form 941 or Form 941-SS and that I have examined this adjusted return or claim, 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’re self-employed . . .

Preparer’s name

Preparer’s signature

Firm’s name (or yours 

if self-employed)

Address

City State

PTIN

Date / /

EIN

Phone

ZIP code

Page 5 Form 941-X (Rev. 7-2021)
Form 941-X: Which process should you use?

Type of errors 

you’re correcting

Unless otherwise specified in the separate instructions, an underreported employment tax credit or social 

security tax deferral should be treated like an overreported tax amount. An overreported employment tax credit 

or social security tax deferral should be treated like an underreported tax amount. For more information, 

including which process to select on lines 1 and 2, see Correcting an employment tax credit or social security tax 

deferral in the separate instructions.

Underreported 

tax amounts 

ONLY

Use the adjustment process to correct underreported tax amounts.

• Check the box on line 1.

• Pay the amount you owe from line 27 by the time you file Form 941-X.

Overreported 

tax amounts 

ONLY

The process you 

use depends on 

when you file 

Form 941-X.

If you’re filing Form 941-X 

MORE THAN 90 days before 

the period of limitations on 

credit or refund for Form 941 

or Form 941-SS expires...

Choose either the adjustment process or the claim 

process to correct the overreported tax amounts.

Choose the adjustment process if you want the

amount shown on line 27 credited to your Form 941, 

Form 941-SS, or Form 944 for the period in which you 

file Form 941-X. Check the box on line 1.

OR

Choose the claim process if you want the amount 

shown on line 27 refunded to you or abated. Check 

the box on line 2.

If you’re filing Form 941-X 

WITHIN 90 days of the 

expiration of the period of 

limitations on credit or refund 

for Form 941 or Form 941-SS...

You must use the claim process to correct the 

overreported tax amounts. Check the box on line 2.

BOTH 

underreported 

and 

overreported 

tax amounts 

The process you 

use depends on 

when you file 

Form 941-X.

If you’re filing Form 941-X 

MORE THAN 90 days before 

the period of limitations on 

credit or refund for Form 941 

or Form 941-SS expires...

Choose either the adjustment process or both the 

adjustment process and the claim process when you 

correct both underreported and overreported tax 

amounts.

Choose the adjustment process if combining your 

underreported tax amounts and overreported tax

amounts results in a balance due or creates a credit 

that you want applied to Form 941, Form 941-SS, or 

Form 944.

• File one Form 941-X, and

• Check the box on line 1 and follow the instructions 

on line 27.

OR

Choose both the adjustment process and the 

claim process if you want the overreported tax

amount refunded to you or abated.

File two separate forms.

1. For the adjustment process, file one Form 941-X 

to correct the underreported tax amounts. Check 

the box on line 1. Pay the amount you owe from 

line 27 by the time you file Form 941-X.

2. For the claim process, file a second Form 941-X 

to correct the overreported tax amounts. Check 

the box on line 2.

If you’re filing Form 941-X 

WITHIN 90 days of the 

expiration of the period of 

limitations on credit or 

refund for Form 941 or 

Form 941-SS...

You must use both the adjustment process and 

the claim process.

File two separate forms.

1. For the adjustment process, file one Form 941-X 

to correct the underreported tax amounts. Check 

the box on line 1. Pay the amount you owe from 

line 27 by the time you file Form 941-X.

2. For the claim process, file a second Form 941-X 

to correct the overreported tax amounts. Check 

the box on line 2.

Page 6 Form 941-X (Rev. 7-2021)