Form 941 (Rev. 1-91)

Page 4

who received no pay during the pay period,
pensioners, or members of the Armed Forces. If
you have only household employees in the pay
period, enter -0-. An entry of 250 or more on
line 1a indicates a need to file wage reports on
magnetic media. You should immediately
request Publication TIB-4 from SSA if not
already a magnetic media filer.

Line 2.—Enter the total of all wages paid, tips
reported, taxable fringe benefits provided, and
other compensation paid to your employees,
even if you do not have to withhold income or
social security and Medicare taxes on it. Do not
include pensions, annuities, supplemental
unemployment compensation benefits, or
gambling winnings, even if you withheld income
tax on them.

When an employer receives timely notice
from its insurance carrier concerning the
amount of third-party sick pay paid, the
employer should include the third-party sick pay
on this line. In these cases, an insurance
company should not include third-party sick pay
that it paid to the employees of policy holders.
See section 19 of Circular E for more details.

Line 3.—Enter the income tax you withheld on
wages, tips, taxable fringe benefits, annuities,
supplemental unemployment compensation
benefits, and gambling winnings. An insurance
company should enter the income tax it
withheld on third-party sick pay here.

Line 4—Adjustment of withheld income
tax.—Use line 4 to correct errors in income tax
withheld from wages paid in earlier quarters of
the same calendar year. Explain any amount on
Form 941¢, Statement to Correct Information,
or attach a statement that shows: (a) what the
error was, (b).quarter in which the error was
made, (c) the amount of the error for each
quarter, (d) quarter in which you found the
error, and (e) how you and your payees have
settled any overcoliection or undercollection. Do
not use this line to adjust income tax
withholding for earlier years.

Line 5—Adjusted total of income tax
withheld.—Add line 4 to line 3 if you are
reporting additional income tax withheld for an
earlier quarter in this calendar year. Subtract
line 4 from line 3 if you are reducing the
amount of income tax withheld. If there is no
entry, on line 4, the entry will be the same as
ine 3.

Line 6a—Taxable social security wages.—
Enter the total wages subject to social security
taxes that you paid your employees during the
quarter. Include the employee social security
tax and the employee state unemployment
compensation tax you paid for your employees
rather than deducting it from their wages. Also
include any sick pay and taxable fringe benefits
subject to social security taxes. Enter the
amount before deductions. Do not include tips
on this line. Stop reporting when an employee's
wages (including tips) reach $53,400 for 1991.
However, continue to withhold income tax for
the whole year on wages and tips even when
the social security wage base of $53,400 is
reached. See line 7 below for Medicare tax. If
none of the payments are subject to social
security tax, enter -O- and attach a statement
explaining why the wages are not subject to
social security tax.

Line 6b—Taxable tips.—Enter all tips your
employees reported during the quarter, until
tips and wages for each employee reach
$53,400 in 1991. Do this even if you were not
able to withhold the employee tax (6.2%).
However, see line 9 instructions below.

An employee must report to you cash tips,
including tips you paid the employee for charge
customers, totaling $20 or more in a month by
the 10th of the next month. The employee may
use Form 4070, Employee's Report of Tips to
Employer, or a written statement.

Yr U.S, GOVERNMENT PRINTING OFFICE 1992-307-725

Do not include allocated tips on this line.
Instead, report them on Form 8027,
Employer’s Annual information Return of Tip
Income and Allocated Tips. Allocated tips are
not reportable on Form 941 and are not subject
to withholding of income, social security, or
Medicare taxes.

Line 7—Taxable Medicare wages and tips.—
Use this line to report all wages and tips
subject to the Medicare portion of social
security. Stop reporting when an employee's
wages and tips reach $125,000 for 1991, If
none of the payments are subject to Medicare
tax, enter -0- and attach a statement explaining
why the wages are not subject to the Medicare
tax.

Include all tips your employees reported
during the quarter, even if you were not able to
withhold the employee tax (1.45%). However,
see line 9 instructions below.

Line 9—Adjustment of social security and
Medicare taxes.—Use line 9 to correct errors
in social security and Medicare taxes reported
on an earlier return or to correct errors in
credits for overpayments of penalty or interest
paid on tax for an earlier quarter. If you report
both an underpayment and an overpayment,
show only the difference. Except for fractions of
cents or third-party sick pay, explain any
amount on line 9 on Form 941c, or attach a
statement that shows: (a) what the error was,
(b) ending date of each quarter in which the
error was made and the amount of the error,
(c) quarter in which you found the error, (d)
that you repaid the employee tax or got each
affected employee's written consent to this
refund or credit, if the entry corrects an
overcollection, and (e) if the entry corrects
social security and Medicare taxes overcollected
in an earlier year, that you got from the
employee a written statement that he or she
has not claimed and will not claim a refund or
credit for the amount. If you are adjusting an
employee's social security wages, tips,
Medicare wages, Medicare tips, or tax withheld
for a prior year, you must also file Form W-2c,
Statement of Corrected Income and Tax
Amounts, and Form W-3c, Transmittal of
Corrected Income and Tax Statements, with the
Social Security office where you filed Forms
W-2. You can get these from IRS.

Enter on Form 941c or include in the
statement the total wages or tips for all your
employees as previously reported and as.
corrected. You can get Form 941c from IRS.

Adjustments of tax on tips and group-term
life insurance premiums paid for former
employees.—Include on line 9 the total
uncollected employee social security and
Medicare taxes. Attach a statement explaining
each adjustment. (See Circular E for details.)

Adjustment of tax on third-party sick pay.—
Deduct on line 9 the social security and
Medicare taxes on third-party sick pay for which
you are not responsible, and write “Sick pay”
in the margin.

Fraction of cents.—If there is a difference
between the total tax on line 8 and the total
deducted from your employees’ wages or tips
because of fractions of cents added or dropped
in collecting the tax, report the difference on
line 9. If this difference is the only entry, write
“Fractions only" in the margin.

Line 10—Adjusted total of social security
and Medicare taxes.—Add line 9 to line 8 if
you are reporting additional taxes for an earlier
quarter. Subtract line 9 from line 8 if you are
reducing the amount of taxes reported for an
earlier quarter or claiming credit for
overpayments of penalty or interest paid on tax
for an earlier quarter.

Line 11—Backup withholding.—Enter the
income tax withheld as backup withholding.

Line 12.—Use line 12 to correct errors in
backup withholding tax for earlier quarters of
this year.

Line 17—Total deposits for quarter.—Enter
the total deposits for the quarter including
backup withholding reported on Schedule A
(Form 941) and any overpayment applied from
the previous quarter from your records.

Line 18—Balance due.—If you deposited all
taxes when due, any balance will be less than
$500. Enter your EIN, “Form 941,” and the tax
period to which the payment applies on your
check or money order.

Line 19—Overpayment.—If you deposited
more than the correct amount for a quarter,
you can have the overpayment refunded or
applied to your next return. Also, the IRS may
apply your overpayment to any past due tax
account that we have under your EIN.

Completing the Record of Federal Tax
Liabliity (ROFT).—Note: This is a record of
when you were liable for taxes, NOT a record of
when you made a deposit.

(a) Line 16 Is less than $500.—You do not
have to complete the ROFT.

(b) Your tax lability is $500 or more but less
than $3,000 for each month of th
quarter.—Only enter your total liability for
each month on the “Total liability for month”
lines (1, Il, and Ill). No entries are required in A
through X.

(c) Your tax liability is $3,000 or more for at
least one month during the quarter but less
than $100,000 during each eighth-monthly
perlod.—Each month is divided into eight
deposit periods (called eighth-monthly periods)
that end on the 3rd, 7th, 11th, 15th, 19th,
22nd, 25th, and last day of the month as
shown in the record. Find the eighth-monthly
period(s) during the quarter in which you had a
payday. Make entries only on the lines next to
these periods. (For example, if you pay wages
on the 1st and 15th of each month, complete
lines A, D, |, L, Q, T, and the monthly Total
lines.) Enter your tax liability (income tax
withheld pius both the employee and employer
social security and Medicare taxes minus any
advance earned income credit payments) for
each eighth-monthly period during which you
had a payday.

(d) Your tax liability is $100,000 or more
during any eighth-monthly period.—You do
not have to complete the ROFT. Instead, you
must complete and attach Schedule B (Form
941), Supplemental Record of Federal Tax
Liability. You must enter the total of Column 2
from Schedule B (Form 941) on line IV of the

Do NOT show Federal tax deposits here. This
information is obtained from the deposit
coupon.

The total of the tax liability column, line IV
(plus line IV on Schedule A (Form 941) if you
treat backup withholding as a separate liability)
should equal “Net taxes” (line 16). Otherwise,
you may be charged a penalty, based on your
average tax liability, for not making deposits of
taxes.

Check the first box at the top of the ROFT
only if you are making deposits using the 95%
rule. This is explained in Circular E.

Check the second box at the top of the
ROFT only if you qualify for the exception
under Rule 4 explained on page 9 of Circular E
and attach a statement showing your net taxes
for each of the preceding 4 calendar quarters.

E..# 36-2705514


rom 941

(Rev. January 1991)

Department of the Treasury
Internal Revenue Service

Employer’s Quarterly Federal Tax Return
> See Circular E for more information concerning employment tax returns.
Please type or print.

4441

Your name, OMB No. 1545-0029
soatence = ~7] Expires: 5-31-93
identification a
number, and
calendar > FF
quarter of FD
‘a re
Correct, L Z| 1
please
change.) 5 2. 3 3 3 3° 3 3 444 U1
If address is 3
different from 3
prior return, a
check here £
5 5 5 6 7 8 8 8 8 8 8 9 9 9 10 10 10 10 10 10 10 10 10 10
If you do not have to file returns in the future, check here . a> oO Date final wages paid od
If you are a seasonal employer, see Seasonal employers on page 2 and check here, >
la Number of employees (except household) employed in the pay period that includes March 12th . » la
b If you are a subsidiary corporation AND your parent corporation files a consolidated Form 1120,
enter parent corporation employer identification number (EIN) _»| 1b]
2 Total wages and tips subject to withholding, plus other compensation > 2
3+ Total income tax withheld from wages, tips, pensions, annuities, sick pay, gambling, etc. > 3
4 Adjustment of withheld income tax for preceding quarters of calendar year (see instructions) . > 4
5 Adjusted total of income tax withheld (line 3 as adjusted by line 4—see instructions) . . . 5
6a Taxable social security wages Complete 6 x 12.4% (124) = [6a
b Taxable social security tips line 7 iB x 12.4% (124) =_| 6b
7 Taxable Medicare wages and tips . B Xx __2.9% (.029) = 7
8 Total social security and Medicare taxes (add lines 6a, 6b, and 7) . 8
9 Adjustment of social security and Medicare taxes (see instructions for required expla nation) . 9
10 Adjusted total of social security and Medicare taxes (line 8 as adjusted by line 9—see instructions) » 10
11 Backup withholding (see instructions) . on 11
12 Adjustment of backup withholding tax for preceding quarters of calendar year, pm (42
13 Adjusted total of backup withholding (line 11 as adjusted byline 12). 13
14 Total taxes (add lines 5, 10, and 13) .. [4
15 Advance earned. income credit (EIC) payments made to employees, if any. re ee)
16 Net taxes (subtract line 15 from line 14). This should equal line IV below (plus line lV of Schedule A
(Form 941) if you have treated backup withholding as a separate liability) . Lo 16
17 Total deposits for quarter, including overpayment applied from a prior quarter, from your records. > 17
18 Balance due (subtract line 17 from line 16). This should be less than $500. Pay to IRS. .> (18
19 Overpayment, if line 17 is more than line 16, enterhere> $___ sand check if to be:
Applied to next return OR _[_] Refunded.

Record of Federal Tax Liability (You must compl

ine 16 is $500 or more and Schedule B is not attached.) See instructions before checking these boxes.

Check only if you made deposits using the 95% rule > Check only if you are a first time 3-banking-day depositor, >
- Show tax liability here, not deposits. IRS gets deposit data from FTD coupons.
Date wages paid .
First month of quarter ‘Second month of quarter Third month of quarter.

> | ist through 3rd A ! Q
— | 4ththrough 7th B J R
ro
$9 8th through 11th c K Ss
£7] 12th through 15th D L T
34] 16th through 19th E M u
23) 20th through 22nd F N Vv
Sg G ie) Ww
2%] 23rd through 25th
8 |_26th through the last H Pp x

Total liability for month | I ul ut
2 IV Total for quarter (add lines J, Il, and II). This should equal line 16 above . >

7 ‘Under penalties of perjury, I declare that Ihave examined this return, including accompanying schedules and statements, and to the best of my knowledge and

Sign belief, itis true, correct, and complete.
Here Signature > Date »

For Paperwork Reduction Act Notice, see page 2.


Form 941 (Rev. 1-91)

Page 2

Paperwork Reduction Act Notice.—We ask
for the information on this form to carry out the
Internal Revenue laws of the United States.

You are required to give us this information. We
need it to ensure that taxpayers are complying
with these laws and to allow us to figure and
collect the right amount of tax.

The time needed to complete and file this
form will vary depending on individual
circumstances. The estimated average time is:
Recordkeeping 12 hrs., 40 min.; Learning
about the law or the form 34 min.; Preparing
the form 1 hr., 44 min,; Copying, assembling,
and sending the form to IRS 16 min. If you
have comments concerning the accuracy of
these time estimates or suggestions for making
this form more simple, we would be happy to
hear from you. You can write to both the
Internal Revenue Service, Washington, DC
20224, Attention: IRS Reports Clearance
Officer, T:FP; and the Office of Management
and Budget, Paperwork Reduction Project
(1545-0029), Washington, DC 20503. DO NOT
send the tax form to either of these offices.
Instead, see the instructions below for
information on where to file.

important Tax Law Changes for 1991.—The
wage bases for the two parts of the social
security tax (social security and Medicare) now
are different. Employers can no longer combine
and report the withholding as a single amount.
Social security wages must be reported on line
6a, social security tips must be reported on line
6b, and Medicare wages and tips must be
reported on line 7. The wage bases are
$53,400 for social security and $125,000 for
Medicare.

The cost of group-term life insurance in
excess of $50,000 provided former employees
is subject to both the employer and employee
portion of social security and Medicare taxes.
Include the cost of the excess coverage on lines
6a and 7. Any uncollected social security and
Medicare taxes must be reported as an
adjustment on line 9.

Forms W-4.—Each quarter, send in with Form
941 copies of any Forms W-4 received during
the quarter from employees: (1) claiming more
than 10 withholding allowances, or (2) claiming
exemption from income tax withholding if their
wages will normally be more than $200 a week.
For details, see section 10 of Circular E.

Circular E, Employer's Tax Guide, explains the
rules for withholding, paying, depositing, and
reporting Federal income tax, social security
and Medicare taxes, and Federal
unemployment (FUTA) tax on wages, fringe
benefits, and sick pay paid by third-party
payers. Circular A, Agricultural Employer's Tax
Guide, explains different rules for employers
who have farmworkers. These circulars are
available free at IRS offices.

General Instructions

Purpose of Form.—To report:

© Income tax you withheld from wages, tips,
annuities, supplemental unemployment
compensation benefits, certain gambling
winnings, and third-party payments of sick pay.
@ Income tax withheld as backup withholding.
© Social security and Medicare taxes.

Who Must File.—Employers who withhold
income tax, and both social security and
Medicare taxes, must file Form 941 quarterly.
Exceptions are:

© Seasonal employers are relieved from filing
Form 941 for quarters when they regularly have
no tax liability because they have paid no
wages. To alert IRS that you will not have to
file a return for one or more quarters during
the year, check the Seasonal employers box
above line 1. IRS will generally not inquire
about unfiled returns if at least one taxable

return is filed each year. However, you must
check the Seasonal employers box on every
quarterly return you file. Otherwise, IRS will
expect a return to be filed for each quarter.

‘@ Employers who report payments not subject
to social security, see Form 941E, Quarterly
Return of Withheld Federal Income Tax and
Medicare Tax, and Circular E.

© Employers who report wages on household
employees, see Form 942, Employer's
Quarterly Tax Return for Household Employees,
and Circular E.

© Employers who report wages on farmworkers,
see Form 943, Employer's Annual Tax Return
for Agricultural Employees, and Circular A.

© Business Reorganization or Termination. If
you sell or transfer your business, both you and
the new owner must file a return for the
quarter in which the change took place. Neither
should report wages paid by the other. (An
example of a transfer is when a sole proprietor
forms a partnership or corporation.) If a change
occurs, please attach to your return a
statement that shows: new owner's name (or
new name of the business); whether the
business is now a sole proprietorship,
partnership, or corporation; kind of change that
took place (sale, transfer, etc.); and date of the
change.

When a business is merged or consolidated
with another, the continuing firm must file the
return for the quarter in which the change took
place. The return should show all wages paid
for that quarter. The other firm should file a
final return

But if you go out of business or stop paying
wages, file a final return. Be sure to fill in the
entries above line 1. You may also file Form
W-2 with the Social Security Administration now
but not later than March 2, 1992.

When To File.—File starting with the first
quarter in which you are required to withhold
income tax or pay wages subject to social
security and Medicare taxes.

Quarter Ending Due Date
Jan.-Feb.-Mar. March 31 April 30
Apr-May-June June 30 July 31
July-Aug-Sept. Sept. 30 Oct. 31
Oct.-Nov.-Dec. Dec. 31 Jan. 31

If you deposited all taxes when due for a
quarter, you have 10 more days after the above
due date to file. If the due date for filing a
return falls on a Saturday, Sunday, or legal
holiday, you may file the return on the first day
afterward that is not a Saturday, Sunday, or
legal holiday.

After you file your first return, we will send
you a form every 3 months. Please use this
form. If you don’t have a form, get one from an
IRS office in time to file the return when due.

Where To File.—

Use the following
Internal Revenue
Service Center
address:

Atlanta, GA 39901

if your legal residence,
principal place of business,
office, or agency Is located in:

Florida, Georgia, South
Carolina

New Jersey, New York
(New York City and
counties of Nassau,
Rockland, Suffolk, and
Westchester)

New York (all other
counties), Connecticut,
Maine, Massachusetts,
New Hampshire, Rhode
Island, Vermont

lllinois, lowa, Minnesota,
Missouri, Wisconsin

Delaware, District of
Columbia, Maryland,
Pennsylvania, Virginia

Holtsville, NY 00501

Andover, MA 05501

Kansas City, MO 64999

Philadeiphia, PA 19255

Indiana, Kentucky, .
Michigan, Ohio, Cincinnati, OH 45999
West Virginia

Kansas, New Mexico,
Oklahoma, Texas

Alaska, Arizona, California
(counties of Alpine, Amador,
Buite, Calaveras, Colusa,
Contra Costa, Del Norte, El
Dorado, Glenn, Humboldt,
Lake, Lassen, Marin,
Mendocino, Modoc, Napa,
Nevada, Placer, Plumas,
Sacramento, San Joaquin,
Shasta, Sierra, Siskiyou,
Solano, Sonoma, Sutter,
Tehama, Trinity, Yolo, and
Yuba), Colorado, Idaho,
Montana, Nebraska, Nevada,
North Dakota, Oregon, South
Dakota, Utah, Washington,
Wyoming

Austin, TX 73301

Ogden, UT 84201

California (all other
counties), Hawaii

Alabama, Arkansas,
Louisiana, Mississippi,
North Carolina, Tennessee

if you have no legal
residence or principal
place of business in
any state

Fresno, CA 93888

Memphis, TN 37501

Philadelphia, PA 19255

Employer Identification Number (EIN).—If
you have not asked for a number, apply for one
on Form $S-4, Application for Employer
Identification Number. Get this form from IRS
or the Social Security Administration (SSA). If
you do not have a number by the time a return
is due, write ‘Applied for” and the date you
applied in the space shown for the number.

Penalties and Interest.—There are penalties
for filing a return late and paying or depositing
taxes late, unless there is reasonable cause. If
you are late, please attach an explanation to
your return. There are also penalties for willful
failure to file returns and pay taxes when due,
furnish Forms W-2 to employees and file copies
with SSA, keep records, deposit taxes when
required, and for filing false returns or
submitting bad checks. See Circular E for
additional information

Interest is charged on taxes paid late at the
rate set by law.

Depositing Taxes.—Use Form 8109, Federal
Tax Deposit Coupon, to deposit your taxes. See
Circular E, section 13, for information and rules
concerning Federal tax deposits.

Do not use the deposit coupons to pay
delinquent taxes for which you have received a
notice from the IRS. These payments should be
sent directly to your Internal Revenue Service
Center along with a copy of any related notice
the IRS sent you

Specific Instructions

Reconciliation of Forms 941 and W-3.—
Certain amounts reported on the four quarterly
Forms 941 for 1991 should agree with the
Forms W-2, Wage and Tax Statement, totals
reported on Form W-3, Transmittal of Income
and Tax Statements, or with information filed
‘on equivalent magnetic media reports filed with
the SSA. The amounts that should agree are:
social security wages, social security tips,
Medicare wages and tips, and the advance
earned income credit. If the totals do not agree,
IRS will require you to explain any differences
and correct any errors. You can avoid this by
making sure that correct amounts (including
adjustments) are reported on Forms 941 and
Line 1—Number of employees.—Complete
for the January-March calendar quarter only.
Do not include household employees, persons

(continued on page 4)


corm 941 Employer’s Quarterly Federal Tax Return

(Rev. January 1991) yyy > See Circular E for more information concerning employment tax returns.
Department of the Treasury .
Internal Revenue Service Please type or print.

Type or print OMB No. 1545-0029

‘adress Name (as distinguished from trade name) Date quarter ended Expires: 5-31-93
employer
identification >

number, and Trade name, ifany Employer identification number

calendar

quarter of
return as
shown on

_ YOUR
COPY

la Number of employees (except household) employed in the pay period that includes March 12th . > la
b If you are a subsidiary corporation AND your parent corporation files a consolidated Form 1120,

Address and ZIP code

If you do not have to file returns inthe future, checkhere. . . ® (_] Date final wages paid
If you are a seasonal employer, see Seasonal employers on page 2 and check here. >

enter parent corporation employer identification number (EIN) ._. >| 1b =

2. Total wages and tips subject to withholding, plus other compensation . . . en 2
3 Total income tax withheld from wages, tips, pensions, annuities, sick pay, gambling, ete. ie 3
4 Adjustment of withheld income tax for preceding quarters of calendar year (see instructions)... > 4
5 Adjusted total of income tax withheld (line 3 as adjusted by line 4—see instructions) . 5
6a Taxable social security wages Complete 6 x 12.4% (124) =| 6a

b Taxable social security tips line 7 & x 12.4% (.124) 6b
7 Taxable Medicare wages and tips . . . & x__2,9% (.029) = _| 7
8 Total social security and Medicare taxes (add lines 6a,6b,and7) . . . oo 8
9 Adjustment of social security and Medicare taxes (see instructions for required explanation) . woe 9

10 Adjusted total of social security and Medicare taxes (line 8 as adjusted by line 9—see instructions) > 10
11 Backup withholding (see instructions) .

12 Adjustment of backup withholding tax for preceding quarters of calendar year. en a 12
13 Adjusted total of backup withholding (line 11 as adjusted byline12) . . . . 2... . . [8
14 Total taxes (addlines5,10,and13) . . . . eo 14 ]
15 Advance earned income credit (EIC) payments made to employees, if any . tone ad 15
16 Net taxes (subtract line 15 from line 14). This should equal line IV below (plus line !V of Schedule A
(Form 941) if you have treated backup withholding as a separate liability). . . . 16
17 Total deposits for quarter, including overpayment applied from a prior quarter, from your records. > 17
18 Balance due (subtract line 17 from line 16). This should be less than $500. PaytoIRS. . . . > 18
19 Overpayment, if line 17 is more than line 16, enter here > $__and check if to be:

(1 Appliedtonextreturn OR [_] Refunded.
Record of Federal Tax Liability (You must complete if line 16 is $500 or more and Schedule B is not attached.) See instructions before checking these boxes.

Check only if you made deposits using the 95% rule > LJ Check only if you are a first time 3-banking-day depositor, . . >
Show tax liability here, not deposits. IRS gets deposit data from FTD coupons.
Date wages paid
First month of quarter Second month of quarter Third month of quarter

) | Astthrough 3rd A ! Q
— | 4ththrough 7th B J R
id
59 8th through 11th Cc K S
22) 12th through 15th D L T
2%) 16th through 19th E M U
2 3} 20th through 22nd F N Vv
3% G oO w
2 %| 23rd through 25th
8" |_26th through the last H P x

Total liability for month | 1 Wn Wh
» 1V Total for quarter (add lines J, Hl, and H). This should equal line 16 above. ss.

. ‘Under penalties of perjury, | declare that | have examined this return, including accompanying schedules and Statements, and to the best of my knowledge and
Sign belief, its true, correct, and complete.

Print Your
Here Signature > Name and Title > Date >