Form 941 - Employer'S Quarterly Federal Tax Return, Form 941-V - Payment Voucher - 2016 Page 2

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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.

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

14 Check one:

$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.

✗

Print your

name here

Sign your

name here

Print your

title here

Date

Best daytime phone

Paid Preparer Use Only

Check if you are self-employed

Preparer’s name