941-SS for 2009:

(Rev. April 2009) 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 complete Form 941-SS. 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

—

Part 1: Answer these questions for this quarter.

1

5

7

8

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)

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) 

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 5d and 7d 

Total deposits for this quarter, including overpayment applied from a 

prior quarter and overpayment applied from Form 941-X or

Form 944-X

Overpayment. If line 13 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

14

5d

7d

.

.

.

. .

.

.

.

.

. .

.

. . ©

For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher. Cat. No. 17016Y Form 941-SS (Rev. 4-2009)

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 

6

9

3

10

(EIN)

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

Balance due. If line 8 is more than line 13, write the difference here

For information on how to pay, see the instructions.

COBRA premium assistance payments (see instructions) 

13 .

.

12a .

13 Add lines 11 and 12a 

Check and go to line 7.

12b Number of individuals provided COBRA premium 

assistance reported on line 12a
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.

17

18

19

Check one: Line 8 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 8.

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-SS.

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?

Page 2 Form 941-SS (Rev. 4-2009)

/ /

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

16

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 IRS.

No.

( ) –

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 ( ) –

Part 5: Sign here. You MUST complete both pages of Form 941-SS 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(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 your payment at an

authorized financial institution or by using the

Electronic Federal Tax Payment System (EFTPS). 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.

● Enclose your check or money order payable to the

“United States Treasury.” Be sure 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 Form 941-SS (or to each

other).

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

payment and Form 941-SS to the address in the

Instructions for Form 941-SS.

To avoid a penalty, make your payment 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 Employers in the U.S. Virgin Islands,

Guam, American Samoa, and the Commonwealth of

the Northern Mariana Islands, for details. In this case,

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

Caution. Use Form 941-V(SS) when making any

payment with Form 941-SS. However, 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 paid 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 Form 941-SS. 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 this voucher or your payment to Form 941-SS.

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-SS.

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-SS 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 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 8 hr., 7 min.

The time needed to complete and file Form 941-SS

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-6526, 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. 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.