Form 941 for 2016:

(Rev. January 2016)

Employer’s QUARTERLY Federal Tax Return

Department of the Treasury — Internal Revenue Service

950114

OMB No. 1545-0029

Employer identification number (EIN) —

Name (not your trade name)

Trade name (if any)

Address

Number Street Suite or room number

City State ZIP code

Foreign country name Foreign province/county Foreign postal code

Report for this Quarter of 2016 

(Check one.)

1: January, February, March

2: April, May, June

3: July, August, September

4: October, November, December

Instructions and prior year forms are 

available at www.irs.gov/form941.

Read the separate instructions before you complete Form 941. Type or print within the boxes.

Part 1: Answer these questions for this quarter.

1 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), or Dec. 12 (Quarter 4) 1

2 Wages, tips, and other compensation . . . . . . . . . . . . . . . . . 2 .

3 Federal income tax withheld from wages, tips, and other compensation . . . . . . 3 .

4 If no wages, tips, and other compensation are subject to social security or Medicare tax Check and go to line 6.

Column 1 Column 2

5a Taxable social security wages . . . × .124 = .

5b Taxable social security tips . . . . × .124 = .

5c Taxable Medicare wages & tips. . . × .029 = . 5d Taxable wages & tips subject to 

Additional Medicare Tax withholding . × .009 = .

5e Add Column 2 from lines 5a, 5b, 5c, and 5d . . . . . . . . . . . . . . . 5e .

5f Section 3121(q) Notice and Demand—Tax due on unreported tips (see instructions) . . 5f .

6 Total taxes before adjustments. Add lines 3, 5e, and 5f . . . . . . . . . . . . 6 .

7 Current quarter’s adjustment for fractions of cents . . . . . . . . . . . . . 7 .

8 Current quarter’s adjustment for sick pay . . . . . . . . . . . . . . . . 8 .

9 Current quarter’s adjustments for tips and group-term life insurance . . . . . . . 9 .

10 Total taxes after adjustments. Combine lines 6 through 9 . . . . . . . . . . . 10 .

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

overpayments applied from Form 941-X, 941-X (PR), 944-X, or 944-X (SP) filed in the 

current quarter . . . . . . . . . . . . . . . . . . . . . . . . . 11 .

12 Balance due. If line 10 is more than line 11, enter the difference and see instructions . . . 12 .

13 Overpayment. If line 11 is more than line 10, enter the difference . Check one: Apply to next return. Send a refund.

▶ You MUST complete both pages of Form 941 and SIGN it. Next ■▶

For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher. Cat. No. 17001Z Form 941 (Rev. 1-2016)
950214

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

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 section 11 

of Pub. 15.

14 Check one: Line 10 on this return is less than $2,500 or line 10 on the return for the prior quarter was less than $2,500, and you did not incur a 

$100,000 next-day deposit obligation during the current quarter. If line 10 for the prior quarter was less than $2,500 but line 10 on this return 

is $100,000 or more, you must provide a record of your federal tax liability. If you are a monthly schedule depositor, complete the deposit 

schedule below; if you are a semiweekly schedule depositor, attach Schedule B (Form 941). Go to Part 3.

You were a monthly schedule depositor for the entire quarter. Enter your tax liability for each month and total 

liability for the quarter, then go to Part 3.

Tax liability: Month 1 .

Month 2 .

Month 3 .

Total liability for quarter . Total must equal line 10.

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.

Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank.

15 If your business has closed or you stopped paying wages . . . . . . . . . . . . . . . Check here, and

enter the final date you paid wages / / .

16 If you are a seasonal employer and you do not have to file a return for every quarter of the year . . Check here.

Part 4: May we speak with your third-party designee?

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 the IRS.

No.

Part 5: Sign here. You MUST complete both pages of Form 941 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

Print your 

title here

Date / / 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 2 Form 941 (Rev. 1-2016)
Form 941-V, 

Payment Voucher

Purpose of Form

Complete Form 941-V if you are making a payment with 

Form 941. We will use the completed voucher to credit 

your payment more promptly and accurately, and to 

improve our service to you.

Making Payments With Form 941

To avoid a penalty, make your payment with Form 941 

only if:

• Your total taxes after adjustments for either the current 

quarter or the preceding quarter (Form 941, line 10) are 

less than $2,500, you didn't incur a $100,000 next-day 

deposit obligation during the current quarter, 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 for details. In this case, 

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

Otherwise, you must make deposits by electronic funds 

transfer. See section 11 of Pub. 15 for deposit 

instructions. Don't use Form 941-V to make federal tax 

deposits.

Use Form 941-V when making any payment with 

Form 941. However, if you pay an amount with

Form 941 that should have been deposited, you 

may be subject to a penalty. See Deposit Penalties in

section 11 of Pub. 15.

Specific Instructions

Box 1—Employer identification number (EIN). If you 

don't have an EIN, you may apply for one online. Go to 

IRS.gov and type “EIN” in the search box. You may also 

apply for an EIN by faxing or mailing Form SS-4 to the 

IRS. If you haven't received your EIN by the due date of 

Form 941, write “Applied For” and the date you applied in 

this entry space.

Box 2—Amount paid. Enter the amount paid with

Form 941.

Box 3—Tax period. Darken the circle identifying the

quarter for which the payment is made. Darken only

one circle.

Box 4—Name and address. Enter your name and

address as shown on Form 941.

• Enclose your check or money order made payable to 

“United States Treasury.” Be sure to enter your 

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

money order. Don't send cash. Don't staple Form 

941-V or your payment to Form 941 (or to each other).

• Detach Form 941-V and send it with your payment 

and Form 941 to the address in the Instructions for 

Form 941.

Note: You must also complete the entity information 

above Part 1 on Form 941.

✁ ▼ Detach Here and Mail With Your Payment and Form 941. ▼ Form 941-V

Department of the Treasury 

Internal Revenue Service 

Payment Voucher

▶ Don't staple this voucher or your payment to Form 941.

OMB No. 1545-0029

2016

1 Enter your employer identification 

number (EIN).

2

Enter the amount of your payment. ▶

Make your check or money order payable to “United States Treasury”

Dollars Cents

3 Tax Period

1st 

Quarter

2nd 

Quarter

3rd 

Quarter

4th 

Quarter

4 Enter your business name (individual name if sole proprietor).

Enter your address.

Enter your city, state, and ZIP code or your city, foreign country name, foreign province/county, and foreign postal code.

✃

▲! CAUTION
Form 941 (Rev. 1-2016)

Privacy Act and Paperwork Reduction Act Notice. 

We ask for the information on Form 941 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 and provides for

income tax withholding. Form 941 is used to determine

the amount of 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 identification number. If you fail to provide this 

information in a timely manner, or provide false or 

fraudulent information, you may be subject to penalties. 

You aren't 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 

its instructions must be retained as long as their contents 

may become material in the administration of any Internal 

Revenue law.

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.

The time needed to complete and file Form 941 will 

vary depending on individual circumstances. The 

estimated average time is:

Recordkeeping . . . . . . . . . . . . . 11 hr.

Learning about the law or the form . . . . 47 min.

Preparing, copying, assembling, and 

sending the form to the IRS . . . . . . . . 1 hr.

If you have comments concerning the accuracy of 

these time estimates or suggestions for making Form 941 

simpler, we would be happy to hear from you. You can 

send us comments from www.irs.gov/formspubs. Click on 

More Information and then click on Give us feedback. Or 

you can send your comments to Internal Revenue 

Service, Tax Forms and Publications Division, 1111 

Constitution Ave. NW, IR-6526, Washington, DC 20224. 

Don't send Form 941 to this address. Instead, see 

Where Should You File? in the Instructions for Form 941.