Form 941-X - Adjusted Employer'S Quarterly Federal Tax Return Or Claim For Refund - 2015 Page 2
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1
2
3
4Name (not your trade name)
Employer identification number (EIN)
Correcting quarter
(1, 2, 3, 4)
Correcting calendar year (YYYY)
Part 3:
Enter the corrections for this quarter. If any line doesn't apply, leave it blank.
Column 2
Column 3
Column 4
Column 1
Amount originally
Difference
Total corrected
reported or as
(If this amount is a
amount (for ALL
Tax correction
previously corrected
negative number,
employees)
=
—
(for ALL employees)
use a minus sign.)
6.
Wages, tips and other
Use the amount in Column 1 when you
=
—
.
.
.
compensation (Form 941, line 2)
prepare your Forms W-2 or Forms W-2c.
7.
Federal income tax withheld
Copy Column
=
from wages, tips, and other
—
.
.
.
.
3 here
▶
compensation (Form 941, line 3)
8.
Taxable social security wages
=
—
(Form 941 or 941-SS, line 5a,
.
.
.
.
× 0.124* =
Column 1)
*If you're correcting your employer share only, use 0.062. See instructions.
9.
Taxable social security tips (Form
=
—
941 or 941-SS, line 5b, Column 1)
.
.
.
.
× 0.124* =
*If you're correcting your employer share only, use 0.062. See instructions.
10.
Taxable Medicare wages and tips
=
—
(Form 941 or 941-SS, line 5c, Column 1)
.
.
.
.
× 0.029* =
*If you're correcting your employer share only, use 0.0145. See instructions.
11.
Taxable wages & tips subject to
=
—
Additional Medicare Tax
.
.
.
.
× 0.009* =
withholding (Form 941 or
*Certain wages and tips reported in Column 3 shouldn't be multiplied by 0.009. See instructions.
941-SS, line 5d)
12.
Section 3121(q) Notice and
=
Copy Column
—
.
.
.
.
Demand—Tax due on
3 here
▶
unreported tips
(Form 941 or 941-SS, line 5f)
13.
Tax adjustments (Form 941 or
=
—
Copy Column
.
.
.
.
941-SS, lines 7–9)
3 here
▶
14.
Qualified small business payroll
=
—
See
.
.
.
.
tax credit for increasing
instructions
research activities (Form 941 or
941-SS, line 11; you must attach
Form 8974)
15.
Special addition to wages for
=
—
See
.
.
.
.
federal income tax
instructions
16.
Special addition to wages for
=
—
See
.
.
.
.
social security taxes
instructions
17.
Special addition to wages for
=
—
See
.
.
.
.
Medicare taxes
instructions
18.
Special addition to wages for
=
—
See
.
.
.
.
Additional Medicare Tax
instructions
.
19.
Combine the amounts on lines 7–18 of Column 4
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
20a.
COBRA premium assistance
=
—
See
.
.
.
.
payments (see instructions)
instructions
20b.
Number of individuals provided
=
—
COBRA premium assistance
(see instructions)
21.
Total. Combine the amounts on lines 19 and 20a of Column 4
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
If line 21 is less than zero:
• If you checked line 1, this is the amount you want applied as a credit to your Form 941 for the tax period in which you're filing this
form. (If you're currently filing a Form 944, Employer’s ANNUAL Federal Tax Return, see the instructions.)
• If you checked line 2, this is the amount you want refunded or abated.
If line 21 is more than zero, this is the amount you owe. Pay this amount by the time you file this return. For information on how to
pay, see Amount you owe in the instructions.
Next
▶
■
2
941-X
Page
Form
(Rev. 4-2017)
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