Form 941 (Rev. 1-2004)

Form 941 Employer’s Quarterly Federal Tax Return

(Rev. January 2004)  See separate instructions revised January 2004 for information on completing this return.

Department of the Treasury

Internal Revenue Service Please type or print.

OMB No. 1545-0029

T

FF

FD

FP

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If address is

different

from prior

return, check

here 

IRS Use

If you do not have to file returns in the future, check here  and enter date final wages paid 

If you are a seasonal employer, see Seasonal employers on page 1 of the instructions and check here 

1 Number of employees in the pay period that includes March 12th 

2 Total wages and tips, plus other compensation (see separate instructions) 2

3 Total income tax withheld from wages, tips, and sick pay 3

4 Adjustment of withheld income tax for preceding quarters of this calendar year 4

5 Adjusted total of income tax withheld (line 3 as adjusted by line 4) 5

6 Taxable social security wages × 12.4% (.124) = 6b

Taxable social security tips 6d

7 Taxable Medicare wages and tips × 2.9% (.029) = 7b

8

Total social security and Medicare taxes (add lines 6b, 6d, and 7b). Check here if wages

are not subject to social security and/or Medicare tax 

8

9

9 Adjustment of social security and Medicare taxes (see instructions for required explanation)

10 Adjusted total of social security and Medicare taxes (line 8 as adjusted by line 9) 10

11 11

12 12

13

13

14

Total taxes (add lines 5 and 10)

14

15

Advance earned income credit (EIC) payments made to employees (see instructions)

15

Net taxes (subtract line 12 from line 11). If $2,500 or more, this must equal line 17,

column (d) below (or line D of Schedule B (Form 941))

16

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

Balance due (subtract line 14 from line 13). See instructions

and check if to be:

Overpayment. If line 14 is more than line 13, enter excess here  $

Applied to next return or Refunded.

● Monthly schedule depositors: Complete line 17, columns (a) through (d), and check here 

× 12.4% (.124) =

1 1 1 1 1 1 1 1 1 2 3 3 3 3 3 3 4 4 4

6 9 7 8 8 8 8 9 9 9 10 10 10 10 10 10 10 10 10 10

1

(a) First month liability (b) Second month liability (c) Third month liability (d) Total liability for quarter

17

Enter state

code for state

in which

deposits were

made only if

different from

state in

address to

the right 

(see page

2 of separate

instructions).

Sick Pay $ ± Fractions of Cents $ ± Other $ =

● Semiweekly schedule depositors: Complete Schedule B (Form 941) and check here 

● All filers: If line 13 is less than $2,500, do not complete line 17 or Schedule B (Form 941).

Monthly Summary of Federal Tax Liability. (Complete Schedule B (Form 941) instead, if you were a semiweekly schedule depositor.)

Name (as distinguished from trade name) Date quarter ended

Trade name, if any Employer identification number

Address (number and street) City, state, and ZIP code

6a

6c

7a

1

3 3 555

8 9 8 8 8

(99)

For Privacy Act and Paperwork Reduction Act Notice, see back of Payment Voucher. Cat. No. 17001Z

Designee’s

name 

Do you want to allow another person to discuss this return with the IRS (see separate instructions)? Third

Party

Designee Phone

no.  ( )

Yes. Complete the following. No

Personal identification

number (PIN) 

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge Sign and belief, it is true, correct, and complete.

Here Print Your

Signature  Name and Title  Date 

A

B
Connecticut, Delaware,

District of Columbia,

Illinois, Indiana, Kentucky,

Maine, Maryland,

Massachusetts, Michigan,

New Hampshire,

New Jersey, New York,

North Carolina, Ohio,

Pennsylvania,

Rhode Island,

South Carolina,

Vermont, Virginia,

West Virginia, Wisconsin

Where to file. In the list below, find the state where your legal residence, principal place of business, office, or

agency is located. Send your return to the Internal Revenue Service at the address listed for your location. No

street address is needed. Note: Where you file depends on whether or not you are including a payment.

RETURN WITHOUT

A PAYMENT

Form 941 (Rev. 1-2004)

RETURN WITH

PAYMENT YOUR LOCATION

Alabama, Alaska, Arizona,

Arkansas, California,

Colorado, Florida, Georgia,

Hawaii, Idaho, Iowa,

Kansas, Louisiana,

Minnesota, Mississippi,

Missouri, Montana,

Nebraska, Nevada,

New Mexico,

North Dakota, Oklahoma,

Oregon, South Dakota,

Tennessee, Texas, Utah,

Washington, Wyoming

No legal residence or

principal place of business

in any state

Cincinnati, OH 45999-0005

Ogden, UT 84201-0005

Philadelphia, PA 19255-0005

P.O. Box 105703

Atlanta, GA 30348-5703

P.O. Box 660264

Dallas, TX 75266-0264

P.O. Box 80106

Cincinnati, OH 45280-0006

Exception for exempt organizations and government entities. If you are filing Form 941 for an exempt

organization or government entity (Federal, state, local, or Indian tribal government), use the following addresses,

regardless of your location:

Return without payment: Ogden, UT 84201-0046

Return with payment: P.O. Box 660264, Dallas, TX 75266-0264

Caution: Your filing or payment address may have changed from prior years. If you are using an IRS provided

envelope, use only the labels and envelope provided with this tax package. Do not send Form 941 or any payments

to the Social Security Administration (SSA).

Who must sign. Form 941 must be signed as follows:

● Sole proprietorship—The individual owning the business.

● Corporation (including an LLC treated as a corporation)—The president, vice president, or other principal officer.

● Partnership (including an LLC treated as a partnership) or unincorporated organization—A responsible and

duly authorized member or officer having knowledge of its affairs.

● Trust or estate—The fiduciary.

The return may also be signed by a duly authorized agent of the taxpayer if a valid power of attorney has been

filed.

● Single-member limited liability company (LLC) treated as a disregarded entity—The owner of the limited

liability company.
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 Circular E (Pub. 15) 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 on the

back of Form 941.

Make your payment with Form 941 only if:

Making Payments With Form 941

● Your net taxes for the quarter (line 13 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 Circular E 

(Pub. 15), 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

Circular E (Pub. 15).

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.

(99)

Form 941-V (2004)

1 Dollars Cents

Note: You must also complete the entity information

above line A on Form 941.

2004
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 the Tax Products Coordinating

Committee, Western Area Distribution Center, Rancho

Cordova, CA 95743-0001. Do not send Form 941 to

this address.

Form 941 (Rev. 1-2004)

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

Electronic filing option. File Form 941 electronically

and receive proof of filing acknowledgement. Electronic

payment options may also be available. Visit the IRS

website at www.irs.gov for details.

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 Federal and state agencies to enforce

Federal nontax criminal laws and to combat terrorism.