941-SS for 2006:

(Rev. October 2006) OMB No. 1545-0029

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 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

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 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) 

TAX ADJUSTMENTS (Read the instructions for line 7 before completing lines 7a through 7h.):

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 (attach Form 941c)

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 

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

Check one Apply to next return.

Send a refund.

Next

3 .124 =

7a

7b

7c

1

8

11

12

5d

7h

.

.

.

. .

.

.

.

.

.

.

.

.

.

.

. ©

.

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 and go to line 7.

6

7d

7f

9

3

10

(EIN)

© You MUST fill out both pages of this form and SIGN it.

Balance due (If line 8 is more than line 11, write the difference here

Make checks payable to United States Treasury.
enter the final date you paid wages .

If your business has closed or you stopped paying wages 

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. 80

(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 liability for quarter Total must equal line 8.

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 

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 speak with your third-party designee?

Part 5: Sign here. You MUST fill out both pages of this form and SIGN it.

Firm’s name

Address EIN

ZIP code

SSN/PTIN

Check if you are self-employed.

Part 6: For PAID preparers only (optional)

Date / / Phone ( ) –

Page 2 Form 941-SS (Rev. 10-2006)

/ /

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

14

Paid Preparer’s

Signature

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

Personal Identification Number (PIN)

No.

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

Date / / Phone ( ) –

Print name and title

Phone ( ) –
Form 941-V(SS),

Payment Voucher

Purpose of Form

Complete Form 941-V(SS), Payment Voucher, 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 Form 941-V(SS) 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.

● Make your check or money order payable to the

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

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

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

941-V(SS) or your payment to the return (or to each

other).

● Detach Form 941-V(SS) and send it with your

payment and Form 941-SS to the address provided in

the Instructions for Form 941-SS (Rev. October 2006).

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 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-SS.

Box 2—Amount paid. Enter the amount you are

paying with Form 941-SS.

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 Tax Return. Ä

OMB No. 1545-0029

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.

1 Dollars Cents

2006

✁ ✃
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. 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 6 hr., 27 min.

The time needed to complete and file this form will

vary depending on individual circumstances. The

estimated average time is:

Learning about the law or the form 18 min.

Preparing the form 24 min.

Copying, assembling, and sending

the form to the IRS 0 min.

If you have comments concerning the accuracy of

these time estimates or suggestions for making Form

941-SS 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-SS to this address. Instead, see Where Should

You File? on page 2 of the Instructions for Form

941-SS.

Form 941-SS (Rev. 10-2006)

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.