Form 941-SS for 2016:

(Rev. January 2016)

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

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

Report for this Quarter of 2016 

(Check one.)

1: January, February, March

2: April, May, June

3: July, August, September

4: October, November, December

Instructions and 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 6.

Column 1 Column 2

5a Taxable social security wages . × .124 = .

5b Taxable social security tips . × .124 = .

5c Taxable Medicare wages & tips . × .029 = . 5d Taxable wages & tips subject to 

Additional Medicare Tax withholding . × .009 = .

5e Add Column 2 from lines 5a, 5b, 5c, and 5d . . . . . . . . . . . . . . . . . 5e .

5f Section 3121(q) Notice and Demand—Tax due on unreported tips (see instructions) . . . 5f .

6 Total taxes before adjustments. Add lines 5e and 5f . . . . . . . . . . . . . . 6 .

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 6 through 9 . . . . . . . . . . . . 10 . 11 Total deposits for this quarter, including overpayment applied from a prior quarter and 

overpayments applied from Form 941-X, 944-X, or 944-X (SP) filed in the current quarter. . 11 .

12 Balance due. If line 10 is more than line 11, enter difference and see instructions . . . . . 12 .

13 Overpayment. If line 11 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. 1-2016)
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 section 8 of Pub. 80. 

14 Check one: Line 10 on this return is less than $2,500 or line 10 on the return for the prior quarter was less than $2,500, 

and you did not incur a $100,000 next-day deposit obligation during the current quarter. If line 10 for the prior 

quarter was less than $2,500 but line 10 on this return 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.

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

enter the final date you paid wages .

16 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. 1-2016)
Form 941-V(SS), 

Payment Voucher

Purpose of Form

Complete Form 941-V(SS) if you are making a payment 

with Form 941-SS. We will use the completed voucher to 

credit your payment more promptly and accurately, and 

to improve our service to you.

Making Payments With Form 941-SS

To avoid a penalty, make your payment with Form 

941-SS only if:

• Your total taxes after adjustments for either the current 

quarter or the preceding quarter (Form 941-SS, line 10) 

are less than $2,500, you didn't incur a $100,000 nextday 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 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 for deposit instructions. 

Don't 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.

Specific Instructions

Box 1—Employer identification number (EIN). If you

don't have an EIN, you may apply for one online. Go to 

IRS.gov and type "EIN" in the search box. You may also 

apply for an EIN by faxing or mailing Form SS-4 to the 

IRS. If you haven't received your EIN by the due date of 

Form 941-SS, 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 

“United States Treasury.” Be sure to enter your EIN, 

“Form 941-SS,” and the tax period on your check or 

money order. Don't send cash. Don't 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

▶ Don't staple this voucher or your payment to Form 941-SS.

OMB No. 1545-0029

2016

1 Enter your employer identification 

number (EIN).

2

Enter the amount of your payment. ▶

Make your check or money order payable to “United States Treasury”

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 or your city, foreign country name, foreign province/county, and foreign postal code.
Form 941-SS (Rev. 1-2016)

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 and provides 

for income tax withholding. Form 941-SS 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.

You aren't 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 hr., 31 min.

Learning about the law or the form . . . . 47 min.

Preparing, copying, assembling, and 

sending the form to the IRS . . . . . . . . 1 hr.

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 send us comments from 

www.irs.gov/formspubs. Click on More Information and 

then click on Give us feedback. Or you can send your 

comments to Internal Revenue Service, Tax Forms and 

Publications Division, 1111 Constitution Ave. NW, 

IR-6526, Washington, DC 20224. Don't send Form 

941-SS to this address. Instead, see Where Should You 

File? in the Instructions for Form 941-SS.