Form 941-SS for 2011:

(Rev. January 2011)

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 2011 

(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 6e.

Column 1 Column 2 For 2011, the employee social 

security tax rate is 4.2% and the 

Medicare tax rate is 1.45%. The 

employer social security tax rate 

is 6.2% and the Medicare tax 

rate is 1.45%.

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 .

6a Reserved for future use.

6b Reserved for future use. Do Not Complete Lines 6a-6d

6c Reserved for future use. . 6d .

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

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 6e through 9 . . . . . . . . . . . . 10 .

11 Total deposits, including prior quarter overpayments . . . . . . . . . . . . . 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. 1-2011)
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

17 Check one: Total taxes (line 10) on this return are less than $2,500 or total taxes on the return for the preceding quarter 

were less than $2,500, and you did not incur a $100,000 next-day deposit obligation during the current 

quarter. If you meet the de minimis exception based on the prior quarter and line 10 for the current quarter 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.

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

enter the final date you paid wages .

19 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. 1-2011)
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 (previously line 8) 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, apply for one on Form SS-4,

Application for Employer Identification Number, and

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

2011

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. 1-2011)

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. This form

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 . . . . 18 min.

Preparing, copying, assembling, and 

sending the form to the IRS . . . . . . . 28 min.

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 write to: Internal Revenue Service, Tax 

Products Coordinating Committee, 

SE:W:CAR:MP:T:T:SP, 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.