941 for 2005:

(Rev. January 2005) OMB No. 1545-0029

Employer’s Quarterly Federal Tax Return

Department of the Treasury — Internal Revenue Service

9901

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 Quarter ...

(Check one.)

1: January, February, March

2: April, May, June

3: July, August, September

4: October, November, December

Form

—

Part 1: Answer these questions for this quarter.

1

2

3

4

5

6

7

8

9

10

11

12

13

5a

5b

5c

5d

7e

7f

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)

Wages, tips, and other compensation

Total 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  .124 =

Taxable social security tips

Taxable Medicare wages & tips  .029 =

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

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

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

Current year’s income tax withholding (Attach Form 941c)

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

Special additions to federal income tax (reserved use)

Special additions to social security and Medicare (reserved use)

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

Total taxes after adjustments (Combine lines 6 and 7h.)

Advance earned income credit (EIC) payments made to employees

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

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

Balance due (lines 10 – 11 = line 12) Make checks payable to the United States Treasury

Overpayment (If line 11 is more than line 10, write the difference here.) Check one Apply to next return.

Send a refund.

Next

 .124 =

7a

7b

7c

7d

1

2

3

6

8

9

10

11

12

5d

7h

.

.

.

.

.

.

. .

.

.

.

.

.

.

.

.

.

.

.

.

.

. .



For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher. Cat. No. 17001Z Form 941 (Rev. 1-2005)

.
enter the final date you paid wages .

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

9902

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, see Pub. 15

(Circular E), section 11.

14

15

16

17

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. 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 10.

You were a semiweekly schedule depositor for any part of this quarter. Fill out Schedule B (Form 941):

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

Check here, and

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? See the

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.

Check here.

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 statements, and to

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 941 (Rev. 1-2005)

/ /

Name (not your trade name) Employer identification number
Form 941-V,

Payment Voucher

Purpose of Form

Complete Form 941-V 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 the amount at an

authorized financial institution or by electronic funds

transfer. (See section 11 of Pub. 15 (Circular E) for

deposit instructions.) Do not use the Form 941-V

payment voucher 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 also to enter

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

check or money order. Do not send cash. Please do

not staple this voucher or your payment to the return

(or to each other).

● Detach the completed voucher and send it with your

payment and Form 941 to the address provided in the

Instructions for Form 941.

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.) This amount may

be $2,500 or more.

Caution. If you pay amounts 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

 Detach Here and Mail With Your Payment and Tax Return. 

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 or attach this voucher to your payment.

Enter your address.

Enter your city, state, and ZIP code.

Form 941-V (2005)

1 Dollars Cents

Note. You must also complete the entity information

above Part 1 on Form 941.

2005
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 this form will

vary depending on individual circumstances. The

estimated average time is:

For Form 941:

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.

Recordkeeping

For Form 941TeleFile:

Learning about the law or the Tax

Record

Preparing the Tax Record

TeleFile phone call 11 min.

5 hr., 30 min.

18 min.

24 min.

If you have comments concerning the accuracy of

these time estimates or suggestions for making this

form 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-6406, Washington, DC 20224. Do not send Form

941 to this address.

Form 941 (Rev. 1-2005)

Printed on recycled paper

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, and the District of Columbia 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.