Form Il-941-X - Amended Quarterly Illinois Withholding Tax Return - 2004

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Illinois Department of Revenue
IL-941-X
Amended Quarterly Illinois Withholding Tax Return
Read this information first.
Which parts must I complete?
Everyone must complete Parts 1, 3, and 4 to report changes to any
You must complete this form to report corrections to Form IL-941.
amounts reported previously on Form IL-941. Complete Part 2 only if
When is Form IL-941-X due?
you are making changes to tax withheld from payments to a recipient.
If your change decreases your tax due, you must file Form IL-941-X
What if I need additional assistance?
no later than
If you need assistance, visit our web site at call our
• three years after the 15th day of the 4th month following the close
Taxpayer Assistance Division at 1 800 732-8866 or
of the calendar year in which the tax was withheld, or
217 782-3336; or call our TDD (telecommunications device for the
• one year after the date the tax was paid.
deaf) at 1 800 544-5304. Our office hours are 8 a.m. to 5 p.m.
Part 1: Complete the following account information.
_______________________________________________________
___ ___ - ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ____/____
Business name
Federal employer identification number
Sequence number
Tax year Qtr.
_______________________________________________________
Are you a sole proprietor?
___ yes ___ no
Owner(s)
If you answered “yes,” write
_______________________________________________________
your Social Security number ___ ___ ___-___ ___- ___ ___ ___ ___
Number and street
_______________________________________________________
Is this a new address?
___ yes ___ no
City
State
ZIP
(
)
-
____________________________
Daytime telephone number
Part 2: Complete recipient information.
(Complete only if you are making changes to taxes withheld from payments to a recipient.)
Complete Columns A through E to correct withholding errors in the current year only. See Booklet IL-700, Illinois Withholding Tax Guide.
Column A
Column B
Column C
Column D
Column E
Recipient’s
Recipient’s name
Amount reported previously on
Net change
Corrected amount
Social Security number
and state of residency
W-2, W-2G, and 1099 forms
increase (decrease)
1
__________________________
________________
________________
________________
___ ___ ___—___ ___—___ ___ ___ ___
__________________________
________________
________________
________________
___ ___ ___—___ ___—___ ___ ___ ___
__________________________
________________
________________
________________
___ ___ ___—___ ___—___ ___ ___ ___
__________________________
________________
________________
________________
___ ___ ___—___ ___—___ ___ ___ ___
Note: If you need additional space, attach a sheet which follows the format above.
2
2
Add Columns C and D and write the result.
________________
________________
3
3
Add Column D, and write the result here and on Part 3, Line 6, Column B.
________________
4
4
Were W-2-Cs issued? ___ yes ___ no If “yes,” write the date the W-2-Cs were issued.
______ /_______/______________
Month
Day
Year
Part 3: Figure your correct withholding.
Column A
Column B
Column C
Amount reported previously
Net change
Corrected amount
increase (decrease)
5
Write the amount of compensation and gambling winnings
5
(including Illinois lottery winnings) subject to withholding.
________________
________________
________________
6
Write the total Illinois Income Tax required to be withheld.
6
(If applicable, complete Part 2 before you write an entry.)
________________
________________
________________
7
Write the total amount of payments ( i.e., EFT, Form IL-501, and
7
Form IL-941) plus any credit or overpayment from a previous quarter.
________________
________________
________________
8
If Line 6, Column C, is more than Line 7, Column C, write the difference.
8
This is the amount of tax you owe. Make your remittance payable to “Illinois Department of Revenue.”
________________
Note: You may be assessed penalties and interest if this amended return is filed after the due date
of your original Form IL-941. If so, we will send you a notice.
9
9
If Line 6, Column C, is less than Line 7, Column C, write the difference. This is the amount of your overpayment.
________________
You must answer the following questions.
a
Do you want your overpayment applied to a subsequent quarter? ___ yes ___ no If “yes,” write the year and quarter.______ /_______
b
Year
Quarter
Do you want your overpayment to be refunded to you?
___ yes ___ no
Note: If you have an unpaid liability, your overpayment will be applied to that liability. Any remaining overpayment will be applied as
you specified on Lines 9a or 9b.
10
Write a detailed explanation of your changes (e.g ., Part 3, Line 5, Column B, is a decrease in wages and tax previously reported for this quarter).
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Part 4: Sign below
Under penalties of perjury, I state that I have examined this form and, to the best of my knowledge, it is true, correct, and complete.
______________________________________________________________________
__________________
(
)
-
Authorized signature (full name)
Title
Date
Daytime telephone number
Mail this return to: Illinois Department of Revenue, P.O. Box 19007, Springfield, IL 62794-9007
This form is authorized as outlined by the Illinois Income Tax Act. Disclosure of this information is REQUIRED. Failure to provide information
could result in a penalty. This form has been approved by the Forms Management Center.
IL-492-0048
IL-941-X (R-12/04)

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