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Part 3: Enter the Corrections for This

4b. Check the box on line 4b to certify that your overreported

amount is only for the employer share of taxes on those

Quarter

employees who you were unable to find or those who would not

(or could not) give you a statement described on line 4a.

What Amounts Should You Report in Part 3?

4c. Check the box on line 4c to certify that your overreported

amount is only for federal income tax, social security tax, and

In columns 1 and 2 of lines 6 through 10, show amounts for all

Medicare tax that you did not withhold from your employees.

of your employees, not just for those employees whose

amounts you are correcting.

5. Certifying Claims

If a correction that you report in column 4 includes both

If you are filing a claim for refund or abatement of overreported

underreported and overreported amounts (see the instructions

federal income tax, social security tax, or Medicare tax and

for line 19 on page 9), give us details for each error on line 23.

checked the box on line 2, check the appropriate box on line 5.

You may need to check more than one box. If you obtained

Because special circumstances apply for lines 11a through

written statements or consents from some employees but you

15 and 17 through 18d, read the instructions for each line

could not locate or secure the cooperation of the remaining

carefully before entering amounts in the columns.

employees, check all applicable boxes. Provide a summary in

line 23 of the amount of the corrections for both the employees

If you previously adjusted or amended Form 941 using

who provided statements or consents and for those who did

Form 941c, Form 941-X, Form 843, an “amended” Form

not. You may not file a refund claim to correct federal income

941, by filing a “supplemental” Form 941, or because of

CAUTION

tax actually withheld from employees.

an IRS examination change, show amounts in column 2 that

include those previously reported corrections.

5a. Check the box on line 5a if your overreported tax includes

each affected employee’s share of social security and Medicare

6. Wages, Tips, and Other Compensation

tax. You are certifying that you repaid or reimbursed to the

If you are correcting the wages, tips, and other compensation

employees their share of prior year social security and

you reported on line 2 of Form 941, enter the total corrected

Medicare tax and you received written statements from those

amount for ALL employees in column 1. In column 2, enter the

employees stating that they did not and will not receive a refund

amount you originally reported. In column 3, enter the

or credit for the prior year taxes.

difference between columns 1 and 2. This line does not apply to

5b. Check the box on line 5b if your overreported tax includes

Form 941-SS.

each affected employee’s share of social security and Medicare

If you (or the IRS) previously corrected the amount reported

tax and you have not yet repaid or reimbursed the employee

on line 2 of Form 941, enter in column 2 the amount after any

share of taxes. You are certifying that you received consent

previous corrections.

from each affected employee to file a claim on the employee

share of those taxes and you received written statements from

line 6 (column 1)

those employees stating that they did not and will not receive a

- line 6 (column 2)

refund or credit for the prior year taxes.

line 6 (column 3)

If the amount in column 2 is larger than the

Example. The following is an example of the consent and

amount in column 1, use a minus sign in

written statement that is required from employees when you are

column 3.

filing a claim for refund and have not yet paid or reimbursed the

Example — Wages, tips, and other compensation

employee share of taxes.

increased: You reported $9,000 as total wages, tips, and

other compensation on line 2 of your 2009 third quarter Form

Employee name

941. In July of 2010, you discovered that you had overlooked

Employer name

$1,000 in tips for one of your part-time employees. To correct

I give my consent to have my employer (named above) file a

the error, figure the difference on Form 941-X as shown.

claim on my behalf with the IRS requesting $_________ in

overcollected social security and Medicare taxes for 20___. I

Column 1 (corrected amount)

10,000.00

have not claimed a refund of or credit for the overcollected

Column 2 (from line 2, of Form 941)

- 9,000.00

taxes from the IRS, or if I did, that claim has been rejected;

Column 3 (difference)

-1,000.00

and I will not claim a refund or a credit of the amount.

Example — Wages, tips, and other compensation

Employee signature

decreased: You reported $9,000 as wages, tips, and other

Date

compensation on line 2 of your 2009 fourth quarter Form 941.

In December of 2010, you discovered that you included $2,000

in wages for one of your employees twice. To correct the error,

Do not send these statements to the IRS. Keep them for

figure the difference on Form 941-X as shown.

your records.

In certain situations, you may not have repaid or reimbursed

Column 1 (corrected amount)

7,000.00

your employees or obtained their consents prior to filing a claim,

Column 2 (from line 2, of Form 941)

- 9,000.00

such as in cases where the period of limitations on credit or

Column 3 (difference)

-2,000.00

refund is about to expire. In those situations, file Form 941-X,

but do not check a box on line 5. Tell us on line 23 that you

Example — Auto allowance; wages, tips, and other

“have not repaid or reimbursed employees or obtained

compensation increased: You paid one of your employees a

consents.” However, you must certify that you have repaid or

$500 monthly auto allowance from October through December

reimbursed your employees or obtained consents before the

2009 and did not treat the payments as taxable wages. In

IRS can grant the claim.

February 2010, you realized that the payments were wages

because they were not reimbursements of deductible business

5c. Check the box on line 5c to certify that your overreported

expenses that were substantiated and paid under an

tax is only for the employer share of social security and

accountable plan. You correct the error by treating the auto

Medicare tax. Affected employees did not give you consent to

allowance as wages subject to income, social security, and

file a claim for refund for the employee share of social security

Medicare taxes. Report the additional $1,500 of wages on lines

and Medicare tax, they could not be found, or would not (or

6, 8, and 10.

could not) give you a statement described on line 5b.

Use the amount in column 1 on line 6 when you prepare

5d. Check the box on line 5d to certify that your overreported

your Forms W-2 or Forms W-2c.

amount is only for federal income tax, social security tax, and

TIP

Medicare tax that you did not withhold from your employees.

-5-

Instructions For Form 941-X - Adjusted Employer'S Quarterly Federal Tax Return Or Claim For Refund - 2010 Page 6

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