Form 941-X:

(Rev. September 2010)

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

Department of the Treasury — Internal Revenue Service 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

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

made on Form 941 or 941-SS for one quarter only. Type or print within the boxes. You

MUST complete all three pages. Do not attach this form to Form 941 or 941-SS.

Return You Are Correcting ...

Check the type of return you are correcting:

941

941-SS

Check the ONE quarter you are 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 are correcting:

(YYYY)

Enter the date you discovered errors:

 / /

(MM / DD / YYYY)

Part 1: Select ONLY one process.

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

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

process to correct the errors. You must check this box if you are correcting both

underreported and overreported amounts on this form. The amount shown on line 20, if

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

944, or Form 944-SS for the tax period in which you are filing this form.

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

claim process to ask for a refund or abatement of the amount shown on line 20. Do not

check this box if you are correcting ANY underreported amounts on this form.

Part 2: Complete the certifications.

3. I certify that I have 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 are correcting underreported amounts only, go to Part 3 on page 2 and skip lines 4 and 5.

4. If you checked line 1 because you are adjusting overreported amounts, 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 for the current year and the overcollected 

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

overcollected in prior years, I have a written statement from each employee stating that he or she has not claimed (or the claim 

was rejected) and will not claim a refund or credit for the overcollection.

b. The adjustment of social security tax and Medicare tax is for the employer’s share only. I could not find the affected employees or 

each employee did not give me a written statement that he or she has not claimed (or the claim was rejected) and will not claim a 

refund or credit for the overcollection.

c. The adjustment is for federal income tax, social security tax, and Medicare tax that I did not withhold from employee wages.

5. If you checked line 2 because you are claiming a refund or abatement of overreported employment taxes, 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 and Medicare tax. For claims of employee 

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

has not claimed (or the claim was rejected) and will not 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 

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

statement from each employee stating that he or she has not claimed (or the claim was rejected) and will not 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 could not find the affected employees; or each 

employee did not give me a written consent to file a claim for the employee’s share of social security and Medicare tax; or each 

employee did not give me a written statement that he or she has not claimed (or the claim was rejected) and will not claim a refund 

or credit for the overcollection.

d. The claim is for federal income tax, social security tax, and Medicare tax that I did not withhold from employee wages.

Next ■▶

For Privacy Act and Paperwork Reduction Act Notice, see the instructions. Cat. No. 17025J Form 941-X (Rev. 9-2010) 
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 does not 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 (from line 2 of

Form 941) . — . = .

Use the amount in Column 1 when 

you prepare your Forms W-2 or 

Forms W-2c.

7. Income tax withheld from 

wages, tips, and other 

compensation (from line 3 of

Form 941)

. — . = . Copy Column 

3 here ▶ .

8. Taxable social security wages 

(from line 5a, Column 1 of Form 

941 or Form 941-SS) . — . = . × .124* = .

*If you are correcting your employer share only, use .062. See instructions.

9. Taxable social security tips 

(from line 5b, Column 1 of Form 

941 or Form 941-SS) . — . = . × .124* = .

*If you are correcting your employer share only, use .062. See instructions.

10. Taxable Medicare wages and 

tips (from line 5c, Column 1 of

Form 941 or Form 941-SS) . — . = . × .029* = .

*If you are correcting your employer share only, use .0145. See instructions.

11a. Number of qualified employees 

first paid exempt wages/tips 

this quarter (from line 6a of Form 

941 or Form 941-SS) 

— =

11b. Number of qualified employees 

paid exempt wages/tips this 

quarter (from line 6b of Form 941 

or Form 941-SS)

— =

11c. Exempt wages/tips paid to 

qualified employees this quarter 

(from line 6c of Form 941 or Form 

941-SS)

. — . = . × .062 = .

12. Tax adjustments (from lines 7a 

through 7c of Form 941 or Form 

941-SS) . — . = . Copy Column 

3 here ▶ .

13. Special addition to wages for 

federal income tax . — . = . See 

instructions .

14. Special addition to wages for 

social security taxes . — . = . See 

instructions .

15. Special addition to wages for 

Medicare taxes . — . = . See 

instructions .

16. Combine the amounts on lines 7–15 of Column 4 . . . . . . . . . . . . . . . . . . . . .

17. Advance earned income credit 

(EIC) payments made to 

employees (from Form 941, line 9)

. — . = . See 

instructions .

18a. COBRA premium assistance 

payments (from line 12a of 

Form 941 or Form 941-SS) . — . = . See 

instructions .

18b. Number of individuals provided 

COBRA premium assistance 

(from line 12b of Form 941 or 

Form 941-SS)

— =

18c. Number of qualified employees 

paid exempt wages/tips 

March 19–31 (from line 12c of 

Form 941 or Form 941-SS)

— =

18d. Exempt wages/tips paid to 

qualified employees 

March 19–31 (from line 12d of

Form 941 or Form 941-SS)

. — . = . × .062 = .

19. Total. Combine the amounts on lines 16–18d of Column 4. Continue on next page . . . . . . . . . . .

Next ■▶

Page 2 Form 941-X (Rev. 9-2010)
Name (not your trade name) Employer identification number (EIN) Correcting quarter (1, 2, 3, 4)

Correcting calendar year (YYYY)

Part 3: Continued

20. Amount from line 19 on page 2 . . . . . . . . . . . . . . . . . . . . . . . . . . .

If line 20 is less than zero:

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

which you are filing this form. (If you are currently filing a Form 944 or Form 944-SS, 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 20 is more than zero, this is the amount you owe. Pay this amount when you file this return. For information on how to 

pay, see Amount You Owe in the instructions.

Part 4: Explain your corrections for this quarter.

21. 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 23.

22. Check here if any corrections involve reclassified workers. Explain on line 23.

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

Part 5: Sign here. You must complete all three 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, they are 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’s use only Check if you are self-employed . . .

Preparer’s name

Preparer’s signature

Firm’s name (or yours 

if self-employed)

Address

City State

Preparer’s 

SSN/PTIN

Date / /

EIN

Phone

ZIP code

Page 3 Form 941-X (Rev. 9-2010)
Version A, Cycle 2

Type of errors Form 941-X: Which process should you use?

you are 

correcting

Underreported 

amounts 

ONLY

Use the adjustment process to correct underreported amounts.

• Check the box on line 1.

• Pay the amount you owe from line 20 when you file Form 941-X.

Overreported 

amounts 

ONLY

The process you 

use depends on 

when you file 

Form 941-X.

If you are 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 process to correct the overreported 

amounts.

Choose the adjustment process if you want the

amount shown on line 20 credited to your Form 941, 

Form 941-SS, Form 944, or Form 944-SS 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 20 refunded to you or abated. Check 

the box on line 2.

If you are 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 amounts. Check the box on line 2.

BOTH 

underreported 

and 

overreported 

amounts 

The process you 

use depends on 

when you file 

Form 941-X.

If you are 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 

amounts.

Choose the adjustment process if combining your 

underreported amounts and overreported amounts results 

in a balance due or creates a credit that you want applied 

to Form 941, Form 941-SS, Form 944, or Form 944-SS.

• File one Form 941-X, and

• Check the box on line 1 and follow the instructions 

on line 20.

OR

Choose both the adjustment process and the 

claim process if you want the overreported amount 

refunded to you or abated.

File two separate forms.

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

to correct the underreported amounts. Check the 

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

20 when you file Form 941-X.

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

to correct the overreported amounts. Check the 

box on line 2.

If you are 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 claim 

process.

File two separate forms.

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

to correct the underreported amounts. Check the 

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

20 when you file Form 941-X.

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

to correct the overreported amounts. Check the 

box on line 2.

Form 941-X (Rev. 9-2010)