Employer’s QUARTERLY Federal Tax Return
Department of the Treasury — Internal Revenue Service — (Check one.)
950113
OMB No. 1545-0029
Employer identification number (EIN) Name (not your trade name) Trade name (if any)
Report for this Quarter of 2013
1: January, February, March 2: April, May, June 3: July, August, September
Address
Number Street Suite or room number
4: October, November, December Instructions and prior year forms are available at www.irs.gov/form941.
City
State
ZIP code
Read the separate instructions before you complete Form 941. Type or print within the boxes.
Part 1:
1
Answer these questions for this quarter.
1 2 3
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) Wages, tips, and other compensation . . . . . . . . . . . . . . . . . . . . . . . . .
2 3 4
Income tax withheld from wages, tips, and other compensation
. .
Check and go to line 6.
If no wages, tips, and other compensation are subject to social security or Medicare tax Column 1
5a 5b 5c 5d
Taxable social security wages . Taxable social security tips . .
. . .
Taxable Medicare wages & tips.
Taxable wages & tips subject to Additional Medicare Tax withholding Add Column 2 from lines 5a, 5b, 5c, and 5d . . .
Section 3121(q) Notice and Demand—Tax due on unreported tips (see instructions) Total taxes before adjustments (add lines 3, 5e, and 5f) . Current quarter’s adjustment for fractions of cents . Current quarter’s adjustment for sick pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Current quarter’s adjustments for tips and group-term life insurance Total taxes after adjustments. Combine lines 6 through 9 . . .
. . . . . . . . . . .
Apply to next return. Send a refund.
Total deposits for this quarter, including overpayment applied from a prior quarter and overpayment applied from Form 941-X or Form 944-X filed in the current quarter . . . COBRA premium assistance payments (see instructions) . . . . . . . . . . . . . . . . . . . . . . . .
11 12a
12a 12b 13 14 15
▶
Number of individuals provided COBRA premium assistance . Add lines 11 and 12a . . . . . . . . . . . . . .
13 14
Balance due. If line 10 is more than line 13, enter the difference and see instructions Overpayment. If line 13 is more than line 10, enter the difference You MUST complete both pages of Form 941 and SIGN it.
.
Check one:
Next ■▶
Cat. No. 17001Z Form 941 (Rev. 1-2013)
For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.
950213
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 Pub. 15 (Circular E), section 11. 16 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
