941 for 2009:

(Rev. April 2009) OMB No. 1545-0029

Employer’s QUARTERLY Federal Tax Return

Department of the Treasury — Internal Revenue Service

950109

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 complete Form 941. Type or print within the boxes.

Report for this Quarter of 2009

(Check one.)

1: January, February, March

2: April, May, June

3: July, August, September

4: October, November, December

Form

(EIN) —

1

2

3

4

5

6

7

8

9

10

11

14

15

5a

5b

5c

5d

7d

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)

Wages, tips, and other compensation 

Income tax withheld from wages, tips, and other compensation 

If no wages, tips, and other compensation are subject to social security or Medicare tax Check and go to line 6.

Taxable social security and Medicare wages and tips:

Column 1 Column 2

Taxable social security wages 3 .124 =

Taxable social security tips

Taxable Medicare wages & tips 3 .029 =

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

Total taxes before adjustments (lines 3 + 5d = line 6) 

CURRENT QUARTER’S ADJUSTMENTS, for example, a fractions of cents adjustment. 

See the instructions.

Current quarter’s fractions of cents 

Current quarter’s sick pay 

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

TOTAL ADJUSTMENTS. Combine all amounts on lines 7a through 7c 

Total taxes after adjustments. Combine lines 6 and 7d 

Advance earned income credit (EIC) payments made to employees 

Total taxes after adjustment for advance EIC (line 8 – line 9 = line 10) 

Total deposits for this quarter, including overpayment applied from a 

prior quarter and overpayment applied from Form 941-X or

Form 944-X

Balance due. If line 10 is more than line 13, write the difference here

Overpayment. If line 13 is more than line 10, write the difference here Check one

Apply to next return.

Send a refund.

Next

3 .124 =

7a

7b

7c

1

2

3

6

8

9

10

14

5d

7d

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For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher. Cat. No. 17001Z Form 941 (Rev. 4-2009)

© You MUST complete both pages of Form 941 and SIGN it.

For information on how to pay, see the instructions.

Part 1: Answer these questions for this quarter.

.

12a COBRA premium assistance payments (see instructions) .

13 Add lines 11 and 12a 13

Number of individuals provided COBRA premium

assistance reported on line 12a

12b
enter the final date you paid wages .

If your business has closed or you stopped paying wages 

950209

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 Pub. 15

(Circular E), section 11.

16

17

18

19

Write the state abbreviation for the state where you made your deposits OR write “MU” if you made your

deposits in multiple states.

Check one: Line 10 is less than $2,500. Go to Part 3.

You were a monthly schedule depositor for the entire quarter. Enter your tax liability

for each month. 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.

Check here, and

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

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

Check here.

Preparer’s signature

Firm’s name (or yours

if self-employed)

Address

EIN

ZIP code

Preparer’s 

SSN/PTIN

Check if you are self-employed 

Date / /

Phone ( ) –

Page 2 Form 941 (Rev. 4-2009)

/ /

Name (not your trade name) Employer identification number (EIN)

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 the IRS.

Part 4: May we speak with your third-party designee?

No.

Part 5: Sign here. You MUST complete both pages of Form 941 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

Print your

name here

Date / / Best daytime phone ( ) –

Paid preparer’s use only

Print your

title here

( ) –

Preparer’s name

City State
Form 941-V,

Payment Voucher

Purpose of Form

Complete Form 941-V, Payment Voucher, if you are

making a payment with Form 941, 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 your payment at an

authorized financial institution or by using the

Electronic Federal Tax Payment System (EFTPS). See

section 11 of Pub. 15 (Circular E) for deposit

instructions. Do not use Form 941-V to make federal

tax deposits.

Specific Instructions

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

do not have an EIN, apply for one on Form SS-4,

Application for Employer Identification Number, and

write “Applied For” and the date you applied in this

entry space.

● Enclose your check or money order made payable to

the “United States Treasury.” Be sure to enter your

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

money order. Do not send cash. Do not staple Form

941-V or your payment to Form 941 (or to each other).

● Detach Form 941-V and send it with your payment

and Form 941 to the address in the Instructions for

Form 941.

To avoid a penalty, make your payment with Form 941

only if:

Making Payments With Form 941

● Your net taxes for the quarter (line 10 on Form 941)

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 11 of Pub. 15 (Circular E),

Employer’s Tax Guide, for details. In this case, the

amount of your payment may be $2,500 or more.

Caution. Use Form 941-V when making any payment

with Form 941. However, if you pay an amount with

Form 941 that should have been deposited, you may

be subject to a penalty. See Deposit Penalties in

section 11 of Pub. 15 (Circular E).

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 identifying the

quarter for which the payment is made. Darken only

one capsule.

Box 4—Name and address. Enter your name and

address as shown on Form 941.

Box 2—Amount paid. Enter the amount paid with

Form 941.

3 Tax period

1st

Quarter

2nd

Quarter

3rd

Quarter

4th

Quarter

Enter the amount of your payment. ©

2

Ä Detach Here and Mail With Your Payment and Form 941. Ä

OMB No. 1545-0029

Form 941-V

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 this voucher or your payment to Form 941.

Enter your address.

Enter your city, state, and ZIP code.

1 Dollars Cents

Note. You must also complete the entity information

above Part 1 on Form 941.

✁ ✃

2009
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 Form 941 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 filers

and paid preparers to provide their identifying

numbers. 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 Form 941 will

vary depending on individual circumstances. The

estimated average time is:

Learning about the law or the form

Preparing the form 

Copying, assembling, and sending

the form to the IRS 16 min.

12 hr., 39 min.

40 min.

1 hr., 49 min.

If you have comments concerning the accuracy of

these time estimates or suggestions for making Form

941 simpler, we would be happy to hear from you. You

can write to: Internal Revenue Service, Tax Products

Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111

Constitution Ave. NW, IR-6526, Washington, DC

20224. Do not send Form 941 to this address. Instead,

see Where Should You File? on page 4 of the

Instructions for Form 941.

Form 941 (Rev. 4-2009)

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.