941-SS for 2005:

(Rev. January 2005) 

Employer’s Quarterly Federal Tax Return

Department of the Treasury — Internal Revenue Service

Employer identification number

Name (not your trade name)

Trade name (if any)

Address

Number Street Suite or room number

City State ZIP code

Read the separate instructions before you fill out this form. Please type or print within the boxes.

Report for this Q

(Check one.)

1: January, Febr

2: April, May, Ju

3: July, August, 

4: October, Nov

Form

—

Part 1: Answer these questions for this quarter.

1

5

7

8

11

12

13

5a

5b

5c

5d

7e

7g

7h

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), Dec. 12 (Quarter 4)

Taxable social security and Medicare wages and tips:

Column 1 Column 2

Taxable social security wages  .124 =

Taxable social security tips

Taxable Medicare wages & tips  .029 =

Total social security and Medicare taxes (Column 2, lines 5a + 5b + 5c = line 5d)

Tax adjustments (If your answer is a negative number, write it in brackets.):

Current quarter’s fractions of cents

Current quarter’s sick pay

Current quarter’s adjustments for tips and group-term life insurance

Prior quarters’ social security and Medicare taxes (Attach Form 941c)

Special additions to social security and Medicare (reserved use)

Total adjustments (Combine all amounts: lines 7a through 7g.)

Total taxes after adjustments (Combine lines 5d and 7h.)

Total deposits for this quarter, including overpayment applied from a prior quarter

Balance due (lines 8 – 11 = line 12) Make checks payable to the United States Treasury

Overpayment (If line 11 is more than line 8, write the difference here.): Check one 

 .124 =

7a

7b

7c

1

8

11

12

5d

7h

.

.

. .

.

.

.

.

.

.

.

For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher. Cat. No. 17016Y Form 9

.

American Samoa, Guam, the Commonwealth of the Northern 

Mariana Islands, and the U.S. Virgin Islands

2

4 If no wages, tips, and other compensation are subject to social security or Medicare tax check her

6

7d

7f

9

3

10
enter the final date you paid wages .

If your business has closed and you do not have to file returns in the future

Part 2: Tell us about your deposit schedule for this quarter.

.

.

.

If you are unsure about whether you are a monthly schedule depositor or a semiweekly schedule depositor, s

(Circular SS), section 8.

15

16

17

Check one: Line 8 is less than $2,500. Go to Part 3.

You were a monthly schedule depositor for the entire quarter. Fill out your tax

liability for each month. Then go to Part 3.

.

Tax liability: Month 1

Month 2

Month 3

Total Total must equal line 8.

You were a semiweekly schedule depositor for any part of this quarter. Fill out Sched

Report of Tax Liability for Semiweekly Schedule Depositors, and attach it to this form.

If you are a seasonal employer and you do not have to file a return for every quarter of the year

Do you want to allow an employee, a paid tax preparer, or another person to discuss this return with the IRS? 

instructions for details.

Yes. Designee’s name

Phone Personal Identification Number (PIN)

Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank.

Part 4: May we contact your third-party designee?

() –

No.

Part 5: Sign here

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and 

the best of my knowledge and belief, it is true, correct, and complete.

✗ Sign your name here

Print name and title

Date / /

Preparer’s signature

Firm’s name

Address EIN

ZIP code

SSN/PTIN

Check if you are self-employed.

Phone () –

Part 6: For paid preparers only (optional)

Date / / Phone () –

Page 2 Form 

/ /

Name (not your trade name) Employer identification n

14
Form 941-V(SS),

Payment Voucher

Purpose of Form

Complete Form 941-V(SS) 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.

Otherwise, you must deposit the amount at an

authorized financial institution or by electronic funds

transfer. See section 8 of Circular SS for deposit

instructions. Do not use the Form 941-V(SS) payment

voucher to make federal tax deposits.

Specific Instructions

Box 1—Employer identification numb

do not have an EIN, apply for one on F

Application for Employer Identification N

write “Applied For” and the date you ap

entry space.

● Make your check or money order pay

“United States Treasury.” Be sure also 

EIN, “Form 941-SS,” and the tax period 

or money order. Do not send cash. Do 

voucher or your payment to the return 

other).

● Detach the completed voucher and s

payment and Form 941-SS to: Internal 

Service, P.O. Box 80106, Cincinnati, OH 

Make payments with Form 941-SS only if:

Making Payments With Form 941-SS

● Your net taxes for the quarter (line 8 on Form

941-SS) are less than $2,500 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 Employees in the U.S. Virgin Islands,

Guam, American Samoa, and the Commonwealth of

the Northern Mariana Islands, for details.) This amount

may be $2,500 or more.

Caution. 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).

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. Box 3—Tax period. Darken the capsule 

quarter for which the payment is made

one capsule.

Box 4—Name and address. Enter you

address as shown on Form 941-SS.

Box 2—Amount paid. Enter the amoun

paying with Form 941-SS.

3 Tax period

1st

Quarter

2nd

Quarter

3rd

Quarter

4th

Quarter

Enter the amount of your payment. 

2

 Detach Here and Mail With Your Payment and Tax Return. 

O

Form 941-V(SS)

Department of the Treasury

Internal Revenue Service

Payment Voucher

Enter your employer identification

number (EIN).

4 Enter your business name (individual name if sole proprietor).

Do not staple or attach this voucher to your payment.

Enter your address.

Enter your city, state, and ZIP code.

(99)

Form 

1 Dollars 
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.

Privacy Act and Paperwork Reduction Act Notice.

We ask for the information on this form 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, including

income tax withholding. 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 employer identification number (EIN). If

you fail to provide this information in a timely manner,

you may be subject to penalties and interest. Recordkeeping 

The time needed to complete and file 

vary depending on individual circumsta

estimated average time is:

Learning about the law or the form 

Preparing the form 

Copying, assembling, and sending

the form to the IRS 

If you have comments concerning the 

these time estimates or suggestions for 

form simpler, we would be happy to he

You can write to: Internal Revenue Serv

Products Coordinating Committee,

SE:W:CAR:MP:T:T:SP, 1111 Constitutio

IR-6406, Washington, DC 20224. Do no

941-SS to this address.

Form 941-SS (Rev. 1-2005)

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, a

states, and the District of Columbia for 

administering their tax laws. We may al

information to other countries under a t

federal and state agencies to enforce fe

criminal laws, or to federal law enforcem

intelligence agencies to combat terroris