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Part 3: Fill this part out ONLY if you

Part 1: Answer these background

are filing more than one Schedule D

questions.

(Form 941) for any calendar year.

1. Check the appropriate box to explain the type of

transaction for which you are submitting Schedule D

If you are filing only one Schedule D (Form 941) for the

(Form 941). See Types of Mergers and Acquisitions on

calendar year, leave this part blank.

page 1 for details.

When more than one statutory merger, consolidation,

File Schedule D (Form 941) after either:

or acquisition occurs during a calendar year, file a

separate Schedule D (Form 941) for each transaction.

a. A statutory merger or consolidation (Check whether

Complete Part 3 for each transaction. For instance, if you

you are an acquired corporation or a surviving

have 11 different transactions in a calendar year, you

corporation.), or

need to file 11 different Schedules D (Form 941). Part 2

b. An acquisition for which you are using the alternate

would be the same for each schedule. Part 3 would show

procedure under Rev. Proc. 2004-53. (Check whether

one of the 11 transactions. For example, the amount

you are a predecessor or a successor.)

entered in Part 2 on line 4 for Column C should equal the

2. Fill in the effective date of the transaction in the

total of all 11 entries in Part 3 on line 10 for Column C.

box. Make sure you write the month, day, and year in this

9. Show the number of schedules you are filing for the

format: MM/DD/YYYY. The year must be the same as the

year and identify which schedule this is. For example, if

calendar year you write in the box at the top of the

you had three different transactions in a calendar year

schedule.

and you are filing a Schedule D (Form 941) to describe

3. Fill in the contact information about the OTHER

the second transaction, fill in “2” and “3” so the sentence

PARTY in the transaction by including the other party’s

reads: “This is schedule 2 of 3. ”

EIN, name, trade name (doing business as or d/b/a),

10-14. For purposes of Part 3, Columns A and B, the

complete address, and phone number. Verify the other

term “employees affected by the transaction reported on

party’s EIN to make sure it is correct.

this Schedule D” means those employees who received

wages that were reported on Forms 941 filed by one

employer but whose wages were reported on Form W-2

Part 2: Tell us about the

(Copy A) filed by another employer as a result of this

discrepancies with your returns.

particular transaction. Report the totals for social security

wages, Medicare wages and tips, social security tips,

4-8. Gather your information about the social security

federal income tax withheld, and advance earned income

wages, Medicare wages and tips, social security tips,

credit (EIC) payments.

federal income tax withheld, and advance earned income

credit (EIC) payments you reported. When entering

In Column A, fill in the amount you reported to the IRS

money amounts from your Forms 941 and W-2 (Copy A)

for the tax year for employees affected by the transaction

on lines 4 -14, you may round to the nearest dollar. Do

reported on this Schedule D (Form 941) for each of the

not show dollar signs but do use commas as appropriate.

items. Add the totals from all your Forms 941, as

Show an amount (even if it is zero) for each column of a

corrected by any Forms 941-X, and write your answers

line.

on the appropriate lines.

In Column B, fill in the amount you reported to SSA for

In Column A, fill in the amount you reported to the IRS

the tax year for employees affected by the transaction

for the tax year for each of the items. Add the totals from

reported on this Schedule D (Form 941) for each of the

all Forms 941, as corrected by any Forms 941-X,

items. Add the totals from all Forms W-2 (Copy A), as

Adjusted Employer’s QUARTERLY Federal Tax Return

corrected by any Forms W-2c (Copy A), and write your

or Claim for Refund, and write your answers on the

answers on the appropriate lines.

appropriate lines.

Calculate the differences between the entries in the

columns:

In Column B, fill in the amount you reported to SSA for

each of the items. Add the totals from all Forms W-2

Column A

(Copy A), as corrected by any Forms W-2c, Corrected

– Column B

Wage and Tax Statement (Copy A), and write your

Column C

answers on the appropriate lines.

Calculate the differences between the entries in the

Enter any negative result in parentheses, if possible.

columns:

For example, if line 12, Column A is “-0-” and line 12,

Column A

Column B is “6,000,” write “(6,000)” in line 12, Column C.

– Column B

If no Forms W-2 (Copy A) were filed by you, write

Column C

“-0-” in Column B, “Amount you reported to SSA

Enter any negative result in parentheses, if possible.

for the tax year.”

CAUTION

For example, if line 6, Column A is “-0-” and line 6,

Column B is “6,000,” write “(6,000)” in line 6, Column C.

Paperwork Reduction Act Notice. We ask for the

If no Forms W-2 (Copy A) were filed by you, write

information on Schedule D (Form 941) to carry out the

“-0-” in column B, “Amount you reported to SSA

Internal Revenue laws of the United States. You are

for the tax year.”

CAUTION

required to give us the information. We need it to ensure

If you are filing for one transaction only, STOP here. If

you are complying with these laws and to allow us to

you are filing for more than one transaction, go to Part 3.

figure and collect the right amount of tax.

-3-

Instructions For Schedule D (Form 941) - Report Of Discrepancies Caused By Acquisitions, Statutory Mergers, Or Consolidations - 2010 Page 3

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