Complete the certifications.

 Select ONLY one process.

Form 943-X:

(Rev. February 2012)

Adjusted Employer’s Annual Federal Tax Return for Agricultural 

Employees or Claim for Refund

Department of the Treasury — Internal Revenue Service OMB No. 1545-0035

Employer identification number 

(EIN) —

Name (not your trade name)

Trade Name (if any)

Number Street Suite or room number

City State ZIP code

Return You Are Correcting ...

Enter the Calendar Year of the return 

you are correcting:

(YYYY)

Enter the date you discovered errors:

(MM / DD / YYYY)

Use this form to correct errors you made on Form 943, Employer’s Annual Federal Tax 

Return for Agricultural Employees. Use a separate Form 943-X for each year that needs 

correction. Please type or print within the boxes. Do not attach this form to Form 943.

You MUST complete all three pages. Read the separate instructions before you complete this form.

Part 1: 

1. Adjusted employment tax return. Check this box if you underreported amounts. Also check this box if you overreported amounts and 

you would like to use the adjustment process to correct the errors. You must check this box if you are correcting both underreported

and overreported amounts on this form. The amount shown on line 18, if less than zero, may only be applied as a credit to your Form 943

for the tax period in which you are filing this form.

2. Claim. Check this box if you overreported amounts only and you would like to use the claim process to ask for a refund or abatement

of the amount shown on line 18. Do not check this box if you are correcting ANY underreported amounts on this form.

Part 2: 

3. I certify that I have filed or will file Forms W-2, Wage and Tax Statement, or Forms W-2c, Corrected Wage and Tax Statement, 

as required.

Note. If you are correcting underreported amounts only, go to Part 3 (skip lines 4 and 5).

4. If you checked line 1 because you are adjusting overreported amounts, check all that apply. (You must check at least one box.)

I certify that:

a. I repaid or reimbursed each affected employee for the social security and Medicare tax overcollected in prior years. I have a

written statement from each employee stating that he or she has not claimed (or the claim was rejected) and will not claim a

refund or credit for the overcollection.

b. The adjustment of social security tax and Medicare tax is for the employer’s share only. I could not find the affected employees or 

each employee did not give me a written statement that he or she has not claimed (or the claim was rejected) and will not claim a 

refund or credit for the overcollection.

c. The adjustment is for federal income tax, social security tax, and Medicare tax that I did not withhold from employee wages.

5. If you checked line 2 because you are claiming a refund or abatement of overreported employment taxes, check all that apply. 

(You must check at least one box.)

I certify that:

a. I repaid or reimbursed each affected employee for the social security and Medicare tax overcollected in prior years. I have a written 

statement from each employee stating that he or she has not claimed (or the claim was rejected) and will not claim a refund or

credit for the overcollection.

b. I have a written consent from each affected employee stating that I may file this claim for the employee’s share of social 

security and Medicare tax overcollected in prior years. I also have a written statement from each employee stating that he or she

has not claimed (or the claim was rejected) and will not claim a refund or credit for the overcollection.

c. The claim for social security tax and Medicare tax is for the employer’s share only. I could not find the affected employees; or each

employee did not give me a written consent to file a refund claim for the employee’s share of social security and Medicare tax; or

each employee did not give me a written statement that he or she has not claimed (or the claim was rejected) and will not claim a 

refund or credit for the overcollection.

d. The claim is for federal income tax, social security tax, and Medicare tax that I did not withhold from employee wages.

Next ■▶

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 20332F Form 943-X (Rev. 2-2012)

Address
Enter the corrections for the calendar year you are correcting. If any line does not apply, leave it blank.

Name (not your trade name) Employer Identification Number (EIN) Calendar Year (YYYY)

Part 3: 

Column 1

Total corrected 

amount (for ALL 

employees)

—

Column 2

Amount originally 

reported or as 

previously corrected 

(for ALL employees)

=

Column 3

Difference 

(If this amount is a 

negative number, use 

a minus sign.)

Column 4

Tax correction

6. Total wages subject to social 

security tax 

(from line 2 of Form 943)

. — . = . × .124* = .

*If you are correcting a 2011 return , use .104. If you are correcting your 

employer share only, use .062. See instructions.

7. Total wages subject to 

Medicare tax 

(from line 4 of Form 943)

. — . = . × .029* = .

*If you are correcting your employer share only, use .0145. See 

instructions.

8. Federal income tax withheld 

(from line 6 of Form 943) . — . = . Copy Column 

3 here ▶ .

9a. Number of qualified 

employees paid exempt 

wages April 1 – December 31, 

2010 (from line 7a of Form 943)*

— = *Complete lines 

9a and 9b only 

for corrections 

to the 2010 

Form 943. 

9b. Exempt wages paid to 

qualified employees April 1 – 

December 31, 2010 (from line 

7b of Form 943)*

. — . = . × .062 = .

10. Tax adjustments 

(from line 8 of Form 943) . — . = . See 

instructions .

11. Special addition to wages for 

federal income tax . — . = . See 

instructions .

12. Special addition to wages for 

social security taxes . — . = . See 

instructions .

13. Special addition to wages for 

Medicare taxes . — . = . See 

instructions .

14. Subtotal: Combine the amounts in lines 6–13 of Column 4 . . . . . . . . . . . . . . . . . . . .

15. Advance earned income 

credit (EIC) payments made 

to employees (from line 10 of 

Form 943; only for years ending 

before January 1, 2011)

. — . = . See 

instructions .

16a. COBRA premium assistance 

payments (from line 11a of Form 

943 (line 13a for years ending 

before January 1, 2011))

. — . = . See 

instructions .

16b. Number of individuals provided 

COBRA premium assistance (from 

line 11b of Form 943 (line 13b for 

years ending before January 1, 2011))

— = *Complete lines 

16c and 16d 

only for 

corrections to 

the 2010 16c. Number of qualified Form 943.

employees paid exempt 

wages March 19–31, 2010 

(from line 13c of Form 943)*

— =

16d. Exempt wages paid to 

qualified employees March 

19–31, 2010 (from line 13d of 

Form 943)*

. — . = . × .062 = .

17. Total. Combine the amounts in lines 14–16d of Column 4. Continue to next page. . . . . . . . . . . . .

Next ■▶

Page 2 Form 943-X (Rev. 2-2012)
Sign here. You must complete all three pages of this form and sign it.

Explain your corrections for the calendar year you are correcting.

Continued

Name (not your trade name) Employer Identification Number (EIN) Calendar Year (YYYY)

Part 3: 

18. Total. Amount from line 17 on page 2 . . . . . . . . . . . . . . . . . . . . . . . . . .

If line 18 is less than zero:

• If you checked line 1, this is the amount you want applied as a credit to your Form 943 for the tax period in which you are filing 

this form.

• If you checked line 2, this is the amount you want refunded or abated.

If line 18 is more than zero, this is the amount you owe. Pay this amount when you file this return. For information on how to 

pay, see Amount you owe in the instructions for line 18.

Part 4: 

19. Check here if any corrections you entered on a line include both underreported and overreported amounts. 

Explain both your underreported and overreported amounts on line 21.

20. Check here if any corrections involve reclassified workers. Explain on line 21.

21. You must give us a detailed explanation for how you determined your corrections. See the separate instructions.

Part 5: 

Under penalties of perjury, I declare that I have filed an original Form 943 and that I have examined this adjusted return or claim and any schedules or 

statements that are attached, and to the best of my knowledge and belief, they are 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

Preparer’s signature

Firm’s name (or yours if 

self-employed)

Address

City State

PTIN

Date

EIN

Phone

ZIP code

Page 3 Form 943-X (Rev. 2-2012)
Type of errors Form 943-X: Which process should you use? you are 

correcting

Underreported 

amounts ONLY

Use the adjustment process to correct underreported amounts.

• Check the box on line 1.

• Pay the amount you owe from line 18 when you file Form 943-X.

Overreported 

amounts ONLY

The process you 

use depends on 

when you file 

Form 943-X.

If you are filing Form 943-X 

MORE THAN 90 days before 

the period of limitations on 

credit or refund for Form 

943 expires . . .

Choose either process to correct the 

overreported amounts.

Choose the adjustment process if you want

the amount shown on line 18 credited to your

Form 943 for the period in which you file Form

943-X. Check the box on line 1.

OR

Choose the claim process if you want the

amount shown on line 18 refunded to you or

abated. Check the box on line 2.

If you are filing Form 943-X 

WITHIN 90 days of the 

expiration of the period of 

limitations on credit or 

refund for Form 943 . . .

You must use the claim process to correct the 

overreported amounts. Check the box on line 2.

BOTH 

underreported 

and 

overreported 

amounts 

The process you 

use depends on 

when you file 

Form 943-X.

If you are filing Form 943-X 

MORE THAN 90 days before 

the period of limitations on 

credit or refund for Form 

943 expires . . .

Choose either the adjustment process or both 

the adjustment process and the claim process 

when you correct both underreported and 

overreported amounts.

Choose the adjustment process if you want to

offset your underreported amounts with your

overreported amounts.

• File one Form 943-X, and

• Check the box on line 1 and follow the 

instructions on line 18.

OR

Choose both the adjustment process and 

claim process if you want the overreported

amount refunded to you.

File two separate forms.

1. For the adjustment process, file one Form 

943-X to correct the underreported amounts. 

Check the box on line 1. Pay the amount you 

owe from line 18 when you file Form 943-X.

2. For the claim process, file a second Form 

943-X to correct the overreported amounts. 

Check the box on line 2.

If you are filing Form 943-X 

WITHIN 90 days of the 

expiration of the period of 

limitations on credit or 

refund for Form 943 . . .

You must use both the adjustment process and 

claim process.

File two separate forms:

1. For the adjustment process, file one Form 

943-X to correct the underreported amounts. 

Check the box on line 1. Pay the amount you 

owe from line 18 when you file Form 943-X.

2. For the claim process, file a second Form 

943-X to correct the overreported amounts. 

Check the box on line 2.

Form 943-X (Rev. 2-2012)