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Example. The following is an example of the written

your employees or obtained consents before the IRS can grant

statement that is required from employees.

the claim.

Employee name

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

Employer name

tax is only for the employer share of social security and

I have received a repayment of $_________ as

Medicare tax. Affected employees did not give you consent to

overcollected social security and Medicare taxes for 20___. I

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

have not claimed a refund of or credit for the overcollected

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

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

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

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

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

Employee signature

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

Date

Medicare tax that you did not withhold from your employees.

Part 3: Enter the Corrections for the

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

your records.

Calendar Year You Are Correcting

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

amount is only for the employer share of taxes on those

What Amounts Should You Report in Part 3?

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

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

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

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

employees, not just for those employees whose amounts you

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

are correcting.

Medicare tax that you did not withhold from your employees.

If a correction you report in column 4 includes both

5. Certifying Claims

underreported and overreported amounts (see the instructions

for line 21), give us details for each error on line 23.

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

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

Because special circumstances apply for lines 11a – 15 and

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

17 – 18d, read the instructions for each line carefully before

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

entering amounts in the columns.

written statements or consents from some employees but you

If you previously adjusted or amended Form 944 by

could not locate or secure the cooperation of the remaining

using Form 941c, Form 944-X, Form 843, an “amended”

employees, check all applicable boxes. Provide a summary on

Form 944, a “supplemental” Form 944, or because of an

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

CAUTION

IRS examination change, show amounts in column 2 that

provided statements or consents and for those who did not. You

include those previously reported corrections.

may not file a refund claim to correct federal income tax actually

6. Wages, Tips, and Other Compensation

withheld from employees.

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

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

each affected employee’s share of prior year social security and

you reported on line 1 of Form 944, enter the total corrected

Medicare tax. You are certifying that you repaid or reimbursed

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

to the employees their share of prior year social security and

amount you originally reported. In column 3, enter the

Medicare tax and you received written statements from those

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

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

Form 944-SS.

or credit for the prior year taxes.

If you or the IRS previously corrected the amount reported

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

on line 1 of Form 944, enter in column 2 the amount after any

each affected employee’s share of prior year social security and

previous corrections.

Medicare tax and you have not yet repaid or reimbursed the

employee share of taxes. You are certifying that you received

line 6 (column 1)

consent from each affected employee to file a claim on the

-line 6 (column 2)

employee share of those taxes and you received written

line 6 (column 3)

If the amount in column 2 is larger than

statements from those employees stating that they did not and

the amount in column 1, use a minus

will not receive a refund or credit for the prior year taxes.

Example. The following is an example of the consent and

Example — Wages, tips, and other compensation

written statement that is required from employees when you are

increased. You reported $900 as total wages, tips, and other

filing a claim for refund and have not yet repaid or reimbursed

compensation on line 1 of your 2010 Form 944. In July of 2011,

the employee share of taxes.

you discovered that you had overlooked $100 in tips for one of

Employee name

your part-time employees. To correct the error, figure the

Employer name

difference on Form 944-X as shown.

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

claim on my behalf with the IRS requesting $_________ in

Column 1 (corrected amount)

1000.00

overcollected social security and Medicare taxes for 20___. I

Column 2 (from Form 944, line 1)

-900.00

have not claimed a refund of or credit for the overcollected

Column 3 (difference)

100.00

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

Example — Wages, tips, and other compensation

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

decreased. You reported $900 as wages, tips, and other

Employee signature

compensation on line 1 of your 2010 Form 944. In December of

Date

2011, you discovered that you included $200 in wages for one

of your employees twice. To correct the error, figure the

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

difference on Form 944-X as shown.

your records.

In certain situations, you may not have repaid or reimbursed

Column 1 (corrected amount)

700.00

your employees or obtained their consents before filing a claim,

Column 2 (from Form 944, line 1)

-900.00

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

Column 3 (difference)

-200.00

refund is about to expire. In those situations, file Form 944-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 consents.

compensation increased. You paid one of your employees a

However, you must certify that you have repaid or reimbursed

$50 monthly auto allowance from October – December 2010

-5-

Instructions for Form 944-X

Instructions For Form 944-X - Adjusted Employer'S Annual Federal Tax Return Or Claim For Refund Page 6

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