Page 4

GENERAL INSTRUCTIONS

The instructions below tell you details for preparing and filing Form
940. Additional instructions are contained in Circular E, which has
been furnished to employers in connection with (a) Income tax with-
holding, (6) taxes under the Federal Insurance Contributions Act, and
(c) the tax under the Federal Unemployment Tax Act. Circular E may
be obtained from your District Director of Internal Revenue upon request.

Employers should refer to Circular E for information as to the em-
ployers who are liable for filing a return on Form 940, the types of pay-
ments defined by law as wages, and the kind of services covered by the
Federal Unemployment Tax Act.

Purpose of Form 940,—This form is provided for the annual reporting
of the tax under the Federal Unemployment Tax Act.

Who must file—Every employer who had 4 or more employees on at
least 1 day of each of 20 calendar weeks in a calendar year must file a
return on Form 940 for such year. Count all regular, temporary, and
part-time employees. A partnership should not count its partners. A
person who works on a continuing basis each week, though not every
day, is considered to be an employee all 7 days in determining whether
4 ot more were employed for at least 20 weeks. In case of a change
of ownership or other transfer of the business during the year, each em-
ployer who had 4 or more employees on at least 1 day of each of 20
calendar weeks in the calendar year must file a return on Form 940, but
neither should report wages paid by the other.

If a statutory merger or consolidation occurs during the calendar year,
the obligation of the continuing corporation to make a return on Form
940, and the reporting of wages and credits on such return, are the same
as if the continuing corporation and the dissolved corporation or corpora-
tions constituted one person during the calendar year.

If you receive a preaddressed form and are not liable for Federal un-
employment tax for 1967 write “not liable” across face of return and
return to the Internal Revenue Service.

‘After you have once filed a retura on Form 940, you should receive a
preaddressed form near the close of each calendar year. If you do not
receive the form, request one from any Internal Revenue Service office so
that you can file your return on time.

Due date of return.—Form 940 is due on or before January 31 for
the preceding calendar year unless the employer obtains from his District
Director an extension of time within which to file the return.

Where to file—Taxpayers whose principal place of business or
principal office or agency is located in Alabama, Florida, Georgia,
Mississippi, North Carolina, South Carolina, or Tennessee should file
original of Form 940 with the Director, Internal Revenue Service Center,
4800 Buford Highway, Chamblee, Georgia 30006. If the principal place
of business or principal office or agency is located in a State other than
those. mentioned, the return should be filed with the District Di-
rector for the district in which the business is located. If the em-
ployer's principal place of business or principal office or agency is not in
the United States file with the Director of International Operations, In-
ternal Revenue Service, Washington, D.C. 20225. Employers whose
principal place of business is in Puerto Rico should file Form 940 (O10)
with the Director of International Operations, U.S. Internal Revenue
Service, Ponce de Leon Avenue and Bolivia Street, Hato Rey, Puerto Rico
00917.

Payment of tax.—Each return Form 940 must be accompanied by the
remittance (cash, check, or money order) for the total tax reported in
item 16.

Employer's name, address, and identification number.—Preaddressed
Forms 940 should be used in filing returns. If the preaddressed form

U.S, GOVERNMENT PRINTING OFFICE

is lost, a new one should be requested. If necessary to use a form not
preaddressed, type or print in the address block the employer's correct
name and address, and enter the employer's identification number in the
space at the right of the address block. Do not use the identification
number assigned to a prior owner.

Penalties and interest.—Avoid penalties and interest by filing a correct
return on time, and by paying the proper amount of tax with the return.
The law provides a penalty for late filing unless reasonable cause is
shown for the del: If you are late in filing a return, send a full
explanation in writing with your return.

Penalties also are imposed by law for willful failure to pay tax, keep
records, make returns, or for false or fraudulent returns,

Credit for contributions paid into State funds.—In general, an em-
ployer may credit against the tax the amount of required contributions
paid by him with respect to the calendar year under all State laws which
have been duly approved: Provided, That no credit will be allowable for
contributions under a State law if such State is not duly certified for the
calendar year. The term “contributions” means payments required by a
State law to be made into an unemployment fund by any person on ac-
count of having individuals in his employ, to the extent that such
payments are made by him without being deducted or deductible from
the remuneration of individuals in his employ. Contributions may be
credited against the tax whether or not they are paid with respect to
“employment.” Do not take credit, however, for voluntary contributions
or for penalty or interest paid to a State.

To be allowable as credit against the tax, contributions must have ac-
tually been paid into a State unemployment fund on or before the due
date of this return or the due date as extended; except that contributions
paid after the due date or the due date as extended, may be credited in
an amount not to exceed 90 percent of the amount which would have
been allowable as credit on account of such contributions had they been
paid on or before such due date.

‘An employer who has been granted an “experience” rate lower than
2.7 percent by a State for the whole, or part, of the year may be entitled
to an additional credit against the tax under Section 3302(b) of the
Federal Unemployment Tax Act. If the provisions of the State law
under which a taxpayer has been granted a reduced rate are not certified,
or are only partially certified, the amount of additional credit claimed
‘on this return may be disallowed in whole or in part.

Under Section 3302(e) a special credit is provided if an employet dur-
ing any calendar year acquires substantially all the property used in the
trade or business (or in a separate unit of a trade or business) of another
person who is not an “employer” (of 4 or more employees on at least
1 day of each of 20 calendar weeks in that year), and immediately after
the acquisition the successor employs in his trade or business one or more
individuals who immediately prior to the acquisition were employed in
the trade or business of the predecessor. This special credit is not allow-
able to any successor employer whose predecessor also is an “employer,”
nor is it allowable to a corporation acquiring the trade or business of
another corporation in a statutory merger or consolidation. The amount
of the special credit is based on the amount of remuneration, subject to
the unemployment compensation law of a State, paid by the predecessor
to those employees who were employed by the predecessor immediately
before the transfer of the trade or business (or separate unit thereof) and
who also were employed by the successor immediately after the transfer.

The total credit allowable under Section 3302 may not exceed 2.7
percent of such wages.

(See also the instructions on the back of copy for the Internal
Revenue Service)

048 —16—79318-1

Schedule B—COMPUTATION OF TAXABLE WAGES

on . (See Schedule B instructions on page 2) .
1. Total remuneration (including exempt remuneration) PAID during the calendar year for services of

employees. ..

Exempt remuneration:
LIST EACH TYPE OF EXEMPTION

Approximate number of

employees involved Amount paid

2. Remuneration in excess of $3,000. (Enter only the excess

over the first $3,000 paid to individual employees)

3. All other exemptions (Explain each exemption shown, at-
taching additional sheet if necessary):

4, Total exempt remuneration.

XXXXXXX/|XXXXXxXXX

5. Total taxable wages (ine 1 minus line 4). Enter this amount in Item 13 on other side...........



FORM 840 EMPLOYER'S ANNUAL FEDERAL UNEMPLOYMENT TAX RETURN—1967

U.S. Treasury Department — Internal Revenue Service
Schedule A— COMPUTATION OF CREDIT AGAINST FEDERAL UNEMPLOYMENT TAX

State reporting number Experience rate pared Contributions bad | contribu able ‘Adsitionat Contributi
Name of Sate | ax ahowr an employer's Taxable Payrol _ Bema | ic rate been 2.1% at enperence tte credit ‘cual paid
State contsibutlon returns | (AS defined! in State act) |~F To rate | (eal. 3 x 2796) X eal. 5) (Col, 6 minus eol, 7) ta State
a @) @) «) 6) @ 9)
TOTALS. . xxxixxx{|xx|xxxx |xxxxxx

10. Total tentative credit (Column 8 plus column 9) .
11, Enter here 2.7% of amount of wages in Item 13 below .
12. Credit allowable (Item 10 or 11 whichever is smaller). Enter here and it in Item 15

EMPLOYERS— DO NOT USE THIS SPACE— CONTINUE BELOW

nunber 2s shoe Taxable Payroll Experience rate period | experience Dates and amounts of contributions Contributions actualy
' [ ‘actually paid to State aid to State before
yer's State (As defined in State act) “From | To tate a pe aid fo State

contribution returns.

TO THE INTERNAL REVENUE SERVICE:
certify that noted above, the records of this office ith the entries made by the empl tumns (2), (3), (4), (5). f
sched fetaey tly that: except as noted above, the records of this oie aaree with the entries made by the employer in columas (2), (3). (4), (5), and (9) of

Signature of

State Officer ....
[7 Namo (as distinguished from trade name) Calendar Year 7 US. TREASURY DEPARTMENT
1967 Internal Revenue Service
Employer's . OFFICIAL BUSINESS
name, Trade name, if any Identification No. POSTAGE AND FEES PAID
addres,
identification Address and ZIP code
number and
calendar . Entries must be made both above and below this line
year. Name (as distinguished from trade name) Calendar Year
(it not 1967
correct
please Trade name, if any Identification No, es
change.) > T
‘Addeoss and ZIP code P
L 1
Hf no lony “ 1 business T
POSTMASTER: If undeliverable treat in accordance with Section 355.56 of Postal Manual. write “Fin:

13. Total taxable wages paid during calendar year (From Schedule B, on other side)...........0..0055
14, Gross Federal tax (3.1% of wages in Item 13)
15. Less: Credit from Item 12 of Schedule A ......... ce eeeeeeennes see eenaceenee setae
16, Remainder of tax (Item 14 minus Item 15). Pay to “INTERNAL REVENUE SERVICE” >.
Tider penalties of perjury, I declare that 1 have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief itis

true, correct, and complete, and that no part of any payment made to a State unemployment fund which is claimed as'a credit in Item 15 above was or is to be deducted
from the rechuneration of employees.

(Title (Owner, president, partner, member, etc.))

BE SURE TO ENCLOSE REMITTANCE WITH THIS RETURN (Form 940)
FILE THIS FORM WITH YOUR INTERNAL REVENUE SERVICE OFFICE NOT LATER THAN JANUARY 31, 1968

(Date)

48 —16—79318-1


Page 2

HOW TO PREPARE SCHEDULE A—COMPUTATION OF CREDIT AGAINST FEDERAL UNEMPLOYMENT TAX

Schedule A should be completely and carefully filled in, in accordance
with the numbered items below, in order that the correct amount of
credit can be determined. All columns (1 to 9) of this schedule are to
be used by taxpayers who have been granted an “experience rate” lower
than 2.7 percent by a State for the whole, or part, of the taxable year.
If you have not been granted an “experience rate,” use columns 1, 2, 3,
and 9 only. If you have been granted an “experience rate” higher
than 2.7 percent, use columns 1, 2, 3, 4, 5, and 9 only. If a State has
granted an experience rate on part of your payroll, that part to which
the experience rate does not apply should be entered separately, using
columns 1, 2, 3, and 9 for this purpose. If you were granted an “ex-
perience rate” for a part of the year only, or your “experience rate”
was changed during the year, show in the proper columns the period
of the year to which each separate rate applied, the payroll, rate of
contributions, and required contributions with respect to each such period.

Column 1.—Enter in column 1 the name of the State or States (in-
duding Puerto Rico) to which contributions were required to be paid.

Column 2.—Enter in column 2 your State reporting number as shown
on your State contribution return. If you had employment in more than
one State, enter the reporting number assigned to you by each such State.

Column 3.—Enter in column 3 the taxable payroll on which you are
required to pay contributions into the unemployment fund of the State
indicated in column 1 of, if you have been granted an “experience rate”
of zero, the amount upon which you would have been required to make
contributions had such rate not been granted.

Column 4.—Enter in column 4 the period or periods of the year to
which the “experience rate” or rates apply.

Column 5.—Enter in column 5 the “experience rate” or rates granted
to you by the State or States for the period or periods shown in column 4.

Column 6.—Section 3302(b) of the Federal Unemployment Tax Act
requires a determination of the amount of contributions an employer
with an “experience rate” would have been required to pay if throughout
the taxable year he had been subject to the highest rate applied by the

State in the taxable year to any person having individuals in his employ
or to a rate of 2.7 percent, whichever rate is lower. For the purpose of
this return, the taxpayer should assume that the highest rate applied under
the State law in the taxable year was not lower than 2.7 percent and use
that rate in computing the amount shown in column 6. If it is deter-
mined that the highest rate applied by the State was lower than 2.7
percent, the amount of additional credit computed with respect to such
State will be reduced accordingly.

Column 7.—Multiply the payroll in column 3 by the “experience rate”
in column 5 and enter the result in column 7.

Column 8.—Subtract the amount in column 7 from the amount in
column 6 and enter the difference in column 8.

Column 9.—Enter in column 9 the amount of contributions actually
paid into the State funds.

Item 10.—Enter the sum of the totals appearing in columns 8 and 9.
Also include the amount of any special credit as explained below.

Special credit—If special credit is claimed as a successor employer,
attach a written statement showing (a) the name, address, and employer
identification number of the predecessor, (b) the method of acquisition of
the predecessor's trade or business (or a separate unit thereof), (c) the
date on which the acquisition occurred, (d) each of the items of informa-
tion in columns 1 through 9 of Schedule A applicable to the predecessor,
(e) the number of individuals employed by the predecessor immediately
ptior to the acquisition who also were employed by the successor employer
immediately after the acquisition, (f) the total amount of remuneration,
subject to the unemployment compensation law of a State, paid to such
employees by the predecessor during the calendar year, The amount of
the special credit is determined by (1) adding the amounts determined
for the predecessor (in step (d), above) as “Additional credit” and as
“Contributions actually paid to State” and (2) multiplying this total by a
fraction of which the numerator is the amount determined in step (f)
above, and the denominator is the amount determined (in step (d), above)
as “Taxable Payroll (as defined in State Act).”

HOW TO PREPARE SCHEDULE B—COMPUTATION OF TAXABLE WAGES

Line 1—Total remuneration (including exempt remuneration)
PAID during the calendar year for services of employees.—Enter in
line 1 of Schedule B the total amount of remuneration for services paid
to employees during the calendar year, regardless of whether such remu-
neration is taxable. Such remuneration should include salaries, wages,
commissions, fees, bonuses, vacation allowances, salaries and wages paid
to temporary or part-time employees, the value of goods, lodging, food
and clothing, and all amounts deducted from employees’ wages as
employee tax or as deductions for other reasons. The basis upon which
the remuneration is paid is immaterial in determining whether the remu-
neration constitutes wages. Thus, it may be paid on the basis of piece-
work, or a percentage of profits; and it may be paid hourly, daily, weekly,
monthly, or annually.

The medium in which the remuneration is paid is also immaterial. It
may be paid in cash of in something other than cash, as for example,
goods, lodging, food, or clothing. Remuneration paid in items other
than cash should be computed on the basis of the fair value of such items
at the time of payment.

Exempt remuneration —The terms “wages” and “employment” as

Gro 16—70318-1

defined for Federal unemployment tax purposes do not include every
payment of remuneration to an employee and every kind of service which
an employee may perform. In general, any remuneration which is ex-
cluded from “wages” and any remuneration for services which are
excepted from “employment,” are not included in the total wages subject
to the tax. These remuneration payments may be deducted from the total
remuneration paid only if they are identified in Schedule B.

Line 2.—Enter in line 2 the approximate number of employees who
received more than $3,000 from you during the year and the aggregate
amount of the excess above $3,000 paid to all of those employees. For
example, assume that you had 10 employees, and that you paid each of
them $5,000 during the year. $50,000 should be included in line 1 and
$20,000 in line 2.

Line 3—Enter in line 3 such items as (1) agricultural labor, (2)
benefit payments for sickness or injury, under a workmen’s compensation
law, insurance plan and certain employer plans, (3) domestic service, (4)
family employment, (5) certain fishing activities, and (6) any other
exempt payments or services. For more definite information with respect
to these exemptions, see Circular E, Employer’s Tax Guide.

(or General Instructions, see back of copy for employer)

Schedule B—COMPUTATION OF TAXABLE WAGES

1, Total remuneration (including exempt remuneration) PAID during the calendar year for services of

Exempt remuneration:
LIST EACH TYPE OF EXEMPTION

Approximate number of

‘employees involved Amount paid

2. Remuneration in excess of $3,000. (Enter only the excess

over the first $3,000 paid to individual employees)...... .

3. All other exemptions (Explain each exemption shown, at-
taching additional sheet if necessary):

4. Total exempt remuneration.

XXXXXXXX

5. Total taxable wages (line 1 minus line 4).
ero 10700181

Enter this amount in Item 13 on other side.



FORM 940 EMPLOYER’S ANNUAL FEDERAL UNEMPLOYMENT TAX RETURN—1967

U.S. Treasury Department — Internal Revenue Service
le A— COMPUTATION OF CREDIT AGAINST FEDERAL UNEMPLOYMENT TAX

Sie ring er seine paid Contiutons had | —contitaton paytiy | Adtonal
Mane Ste | hme ne | cas dete nS ae) |=) ——_—| Pam] a ean ea (col 6 a. 2)
conten tras ‘ (ats el Bel aa
o Q) @) for te | oe (a) 8)

TOrTALs.. XX | xxx | xx [xxx x

10. Total tentative credit (Column 8 plus column 9)......
11. Enter here 2.7% of amount of wages in Item 13 below
12, Credit allowable (Item 10 or 11 whichever is smaller). Enter here and in Item 15.

THIS COPY MUST BE
KEPT BY EMPLOYER

This copy, and a copy of each related schedule of statement which you are required to keep, must be retained for a period of 4 years
after the date the tax is due or paid, whichever is the later, These copies should be available for inspection by officers of the Internal

Revenue Service,
\ Calendar Year
A \\ 1967
\ detiatin No.

<a) er

Identification No,

13, Total taxable wages paid during calendar year (From Schedule B, on. other side) .
14, Gross Federal tax (3.1% of wages in Item 13) sees

15. Less: Credit from Item 12 of Schedule A
16. Remainder of tax (Item 14 minus Item 15). Pay to “{NTERNAL REVENUE SERVIC! —

IMPORTANT.—Before filing the return be sure to enter on this copy your name, address, and identification number.

16—70018-1