Looking for a Form 941-x Templates? Download it for free!

certifying that you adjusted federal income tax withheld from

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

employees for the current calendar year only.

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 24 that you

Example. The following is an example of the written

have not repaid or reimbursed employees or obtained consents.

statement that is required from employees.

However, you must certify that you have repaid or reimbursed

Employee name

your employees or obtained consents before the IRS can grant

Employer name

the claim.

I have received a repayment of $_________ as

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

overcollected social security and Medicare taxes for 20___. I

have not claimed a refund of or credit for the overcollected

tax is only for the employer share of social security and

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

Medicare taxes. Affected employees did not give you consent to

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

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

Employee signature

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

Date

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

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

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

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

your records.

Medicare tax that you did not withhold from your employees.

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

Part 3: Enter the Corrections for This

amount is only for the employer share of taxes on those

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

Quarter

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

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

What Amounts Should You Report in Part 3?

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

Medicare tax that you did not withhold from your employees.

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

5. Certifying Claims

employees, not just for those employees whose amounts you

are correcting.

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

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

If a correction that you report in column 4 includes both

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

underreported and overreported amounts (see the instructions

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

for lines 20 – 21 on page 9), give us details for each error on line

written statements or consents from some employees but you

24.

could not locate or secure the cooperation of the remaining

Because special circumstances apply for lines 11 – 16 and

employees, check all applicable boxes. Provide a summary on

18 – 19d, read the instructions for each line carefully before

line 24 of the amount of the corrections for both the employees

entering amounts in the columns.

who provided statements or consents and for those who did

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

If you previously adjusted or amended Form 941 by

tax actually withheld from employees.

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

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

Form 941, a “supplemental” Form 941, or because of an

CAUTION

each affected employee’s share of social security and Medicare

IRS examination change, show amounts in column 2 that

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

include those previously reported corrections.

employees their share of social security and Medicare taxes.

6. Wages, Tips, and Other Compensation

For refunds of employee social security and Medicare taxes

overcollected in prior years, you are certifying that you received

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

written statements from those employees stating that they did

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

not and will not receive a refund or credit for the prior year

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

taxes.

amount you originally reported. In column 3, enter the

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

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

Form 941-SS.

each affected employee’s share of social security and Medicare

taxes and you have not yet repaid or reimbursed the employee

If you or the IRS previously corrected the amount reported

share of taxes. You are certifying that you received consent

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

from each affected employee to file a claim on the employee

previous corrections.

share of those taxes and you received written statements from

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

line 6 (column 1)

refund or credit for the prior year taxes.

- line 6 (column 2)

Example. The following is an example of the consent and

line 6 (column 3)

If the amount in column 2 is larger than the

written statement that is required from employees when you are

amount in column 1, use a minus sign in

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

column 3.

employee share of taxes.

Example — Wages, tips, and other compensation

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

Employee name

other compensation on line 2 of your 2009 third quarter Form

Employer name

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

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

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

claim on my behalf with the IRS requesting $_________ in

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

overcollected social security and Medicare taxes for 20___. I

have not claimed a refund of or credit for the overcollected

Column 1 (corrected amount)

10,000.00

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

Column 2 (from line 2, of Form 941)

- 9,000.00

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

Column 3 (difference)

-1,000.00

Employee signature

Example — Wages, tips, and other compensation

Date

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

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

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

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

your records.

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

In certain situations, you may not have repaid or reimbursed

figure the difference on Form 941-X as shown.

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

-5-

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 6

Related Articles

Related forms

Related Categories