Schedule R (Form 941): Allocation Schedule for Aggregate Form 941 Filers

(Rev. June 2021) Department of the Treasury — Internal Revenue Service OMB No. 1545-0029

950421

Employer identification number (EIN) —

Name as shown on Form 941

Type of filer (check one): Section 3504 Agent CPEO Other Third Party

Report for calendar year:

2021

Check the quarter (same as Form 941):

1: January, February, March

2: April, May, June

3: July, August, September

Read the instructions before you complete Schedule R. Type or print within the boxes. Complete a separate line for the amounts 4: October, November, December

allocated to each of your clients. The term “client” as used on this form includes the term “customer.” See the instructions.

 (a) Client’s EIN (b) Type of wages 

(CPEO only)

(c) Form 941, line 1 (d) Form 941, line 2 (e) Form 941, line 3 (f) Form 941, lines 5a(i) 

and 5a(ii), column 1, total

(g) Form 941, lines 5a 

and 5b, column 2, total 

(h) Form 941, line 5c, 

column 2

(i) Form 941, line 5e

 

1 . . . . . .

2 . . . . . .

3 . . . . . .

4 . . . . . .

5 . . . . . .

6 Subtotals for clients. Add lines 1 through 5 . . . . . .

7 Enter the combined subtotal from line 9 of 

all Continuation Sheets for Schedule R . . . . . .

8 Enter Form 941 amounts for your employees . . . . . .

9 Totals. Add lines 6, 7, and 8. . . . . . .

 (j) Form 941, line 5f (k) Form 941, line 11a (l) Form 941, lines 11b 

and 13c, total

(m) Form 941, lines 11c 

and 13d, total

(n) Form 941, lines 11d 

and 13e, total

(o) Form 941, lines 11e 

and 13f, total

(p) Form 941, line 11f (q) Form 941, line 12

 

1 . . . . . . .

2 . . . . . . .

3 . . . . . . .

4 . . . . . . .

5 . . . . . . .

6 . . . . . . .

7 . . . . . . .

8 . . . . . . .

9 . . . . . . .

 (r) Form 941, line 13a (s) Form 941, line 13h (t) Form 941, line 18b 

checkbox (Answer Yes or No)

(u) Form 941, lines 19 

and 20, total

(v) Form 941, lines 21 

and 22, total

(w) Form 941, lines 23 

and 25, total

(x) Form 941, lines 24 

and 27, total

(y) Form 941, lines 26 

and 28, total 

1 . . . . . . .

2 . . . . . . .

3 . . . . . . .

4 . . . . . . .

5 . . . . . . .

6 . . . . . . .

7 . . . . . . .

8 . . . . . . .

9 . . . . . . .

For Paperwork Reduction Act Notice, see the separate instructions. www.irs.gov/Form941 Cat. No. 49301K Schedule R (Form 941) (Rev. 6-2021)
Page of

Continuation Sheet for Schedule R (Form 941)

(Rev. June 2021)

950521

Employer identification number (EIN) —

Name as shown on Form 941

Type of filer (check one): Section 3504 Agent CPEO Other Third Party

Report for calendar year:

2021

Check the quarter (same as Form 941):

1: January, February, March

2: April, May, June

3: July, August, September

4: October, November, December

 (a) Client’s EIN (b) Type of wages 

(CPEO only)

(c) Form 941, line 1 (d) Form 941, line 2 (e) Form 941, line 3 (f) Form 941, lines 5a(i) 

and 5a(ii), column 1, total

(g) Form 941, lines 5a 

and 5b, column 2, total

(h) Form 941, line 5c, 

column 2

(i) Form 941, line 5e

 

1 . . . . . .

2 . . . . . .

3 . . . . . .

4 . . . . . .

5 . . . . . .

6 . . . . . .

7 . . . . . .

8 . . . . . .

9 Subtotals for clients. Add lines 1 through 8. 

Include the subtotals from this line on 

Schedule R, Page 1, line 7. . . . . . .

 (j) Form 941, line 5f (k) Form 941, line 11a (l) Form 941, lines 11b 

and 13c, total

(m) Form 941, lines 11c 

and 13d, total

(n) Form 941, lines 11d 

and 13e, total

(o) Form 941, lines 11e 

and 13f, total

(p) Form 941, line 11f (q) Form 941, line 12

 

1 . . . . . . .

2 . . . . . . .

3 . . . . . . .

4 . . . . . . .

5 . . . . . . .

6 . . . . . . .

7 . . . . . . .

8 . . . . . . .

9 . . . . . . .

 

1 . . . . . . .

2 . . . . . . .

3 . . . . . . .

4 . . . . . . .

5 . . . . . . .

6 . . . . . . .

7 . . . . . . .

8 . . . . . . .

9 . . . . . . .

 (r) Form 941, line 13a (y) Form 941, lines 26 

and 28, total 

(x) Form 941, lines 24 

and 27, total

(u) Form 941, lines 19 

and 20, total

(s) Form 941, line 13h (t) Form 941, line 18b 

checkbox (Answer Yes or No)

(w) Form 941, lines 23 

and 25, total

(v) Form 941, lines 21 

and 22, total

Schedule R (Form 941) (Rev. 6-2021)