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corrected amount for ALL employees in column 1. In column 2,

whether or not the reduced premium was for insurance that

enter the amount you originally reported or as previously

covered more than one assistance eligible individual. For

corrected. In column 3, enter the difference between columns 1

example, if the reduced COBRA premium was for coverage for

and 2. This line does not apply to Form 941-SS.

a former employee, spouse, and two children, you would

include one individual in the number entered on line 19b for the

line 18 (column 1)

premium assistance reported on line 19a. Further, each

- line 18 (column 2)

individual is reported only once per quarter. For example, an

line 18 (column 3)

If the amount in column 2 is larger than the

assistance eligible individual who made monthly premium

amount in column 1, use a minus sign in

payments during the quarter would only be reported as one

column 3.

individual on line 19b for that quarter.

Copy the amount in column 3 to column 4. However, to

Enter in column 2 on line 19b the number of assistance

properly show the correction as a credit or balance due

eligible individuals provided COBRA premium assistance

item, enter a positive number in column 3 as a negative

originally reported on line 12b of Form 941.

CAUTION

number in column 4 or a negative number in column 3 as a

Lines 19c and 19d apply only to the second quarter of

positive number in column 4. Remember, negative amounts in

2010. These lines are used to report the number of

column 4 represent credits and positive amounts in column 4

qualified employees, amount of exempt wages/tips, and

represent additional tax.

CAUTION

amount of employer social security tax exemption as if the

Examples: If line 18, column 3 shows “560.00,” enter

exemption were allowed for the first quarter of 2010.

“-560.00” in column 4.

19c. Number of Qualified Employees Paid

If line 18, column 3 shows “-990.00,” enter “990.00” in

Exempt Wages/Tips March 19–31

column 4.

Example — Advance EIC payments increased: You filed

Complete this line when correcting Form 941 for the second

your 2010 fourth quarter Form 941 reporting zero (line left

quarter of 2010 only. Enter on line 19c (column 1) the corrected

blank) on line 9. On February 17, 2011, you discovered that you

number of qualified employees paid exempt wages/tips from

forgot to report the $1,000 in advance EIC payments you made

March 19, 2010, through March 31, 2010. Include only qualified

on behalf of John Smith, one of your employees. You made no

employees for whom you are claiming the exemption. Enter on

other EIC payments for your other employees. This is an

line 19c (column 2) the number of qualified employees originally

example of an administrative error. To correct the error, file

reported on line 12c of the second quarter 2010 Form 941. If

Form 941-X showing the following.

you are not correcting line 12c of the second quarter 2010 Form

941 but you are making a correction on line 19d, enter the

Column 1 (corrected amount)

1,000.00

amount from line 12c of the second quarter 2010 Form 941 on

Column 2 (from line 9 of Form 941)

- 0.00

line 19c. For the definition of qualified employee, see the

Column 3 (difference)

1,000.00

instructions for line 12a.

Reverse the mathematical sign of the amount in column 3

19d. Exempt Wages/Tips Paid to Qualified

and enter your correction in column 4.

Employees March 19-31

Column 4 (tax correction)

-1,000.00

Complete this line when correcting Form 941 for the second

quarter of 2010 only. Enter on line 19d the amount of exempt

Be sure to explain the reasons for this correction on line 24.

wages/tips paid to qualified employees from March 19, 2010,

through March 31, 2010. For the definition of exempt wages/

See section 13 of Pub. 15 (Circular E) for more

tips, see the instructions for line 12a. Enter the corrected

information about administrative errors and corrections

amount in column 1. In column 2, enter the amount you

during the calendar year. The same rules that apply to

CAUTION

originally reported or as previously corrected. In column 3, enter

withheld federal income taxes also apply to advance EIC

the difference between columns 1 and 2. If the amount in

payments made to employees.

column 2 is larger than the amount in column 1, use a minus

19a. COBRA Premium Assistance Payments

enter the result in column 4. However, to properly show the

If you are correcting the total COBRA premium assistance

correction as a credit or balance due item, enter a positive

payments reported on line 12a of Form 941, report on this line

number in column 3 as a negative number in column 4 or a

65% of the COBRA premiums for assistance eligible

negative number in column 3 as a positive number in column 4.

individuals. Report the premium assistance credit on this line

only after the assistance eligible individual’s 35% share of the

20–21. Total

premium has been paid. For COBRA coverage provided under

Combine lines 17 – 19d of column 4 and enter the result on line

a self-insured plan, COBRA premium assistance is treated as

20. Copy the amount from line 20 on page 2 to line 21 on

having been made for each assistance eligible individual who

page 3.

pays 35% of the COBRA premium.

Your credit. If the amount entered on line 21 is less than zero,

Do not include the assistance eligible individual’s 35% of the

for example, “-115.00,” you have a credit because you

premium in the amount entered on this line. For more

overreported your federal employment taxes.

information on the COBRA premium subsidy, visit IRS.gov and

•

If you checked the box on line 1, include this amount on line

enter the keyword COBRA.

11 (“Total deposits” line) of Form 941 for the quarter during

Copy the amount in column 3 to column 4. However, to

which you filed Form 941-X or line 8 (“Total deposits” line) of

properly show the correction as a credit or balance due item,

Form 944 for the year during which you filed Form 941-X. Do

enter a positive number in column 3 as a negative number in

not make any changes to your record of federal tax liability

column 4 or a negative number in column 3 as a positive

reported on line 17 of Form 941 or Schedule B (Form 941), if

number in column 4. This is the same procedure as the

your Form 941-X is filed timely. The amounts reported on the

advance EIC on line 18.

record should reflect your actual tax liability for the period.

•

If you checked the box on line 2, you are filing a claim for

19b. Number of Individuals Provided COBRA

refund or abatement of the amount shown.

Premium Assistance on line 19a

If your credit is less than $1, we will send a refund or apply it

Complete this line only if you are correcting line 12b of Form

only if you ask us in writing to do so.

941. Enter in column 1 on line 19b the corrected number of

assistance eligible individuals provided COBRA premium

Amount you owe. If the amount on line 21 is a positive

assistance. Count each assistance eligible individual who paid

number, you must pay the amount you owe by the time you file

a reduced COBRA premium in the quarter as one individual,

Form 941-X. You may not use any credit that you show on

-9-

Instructions for Form 941-X (Rev. 1-2011)

Instructions For Form 941-X - Adjusted Employer'S Quarterly Federal Tax Return Or Claim For Refund - 2011 Page 10

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