Form 941-Ss Draft - Employer'S Quarterly Federal Tax Return - American Samoa, Guam, The Commonwealth Of The Northern Mariana Islands, And The U.s. Virgin Islands - 2017 Page 2

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Employer’s QUARTERLY Federal Tax Return
941-SS for 2017:
Form
American Samoa, Guam, the Commonwealth of the Northern
(Rev. January 2017)
Mariana Islands, and the U.S. Virgin Islands
Department of the Treasury — Internal Revenue Service
OMB No. 1545-0029
Report for this Quarter of 2017
0
0
—
3
9
9
9
9
9
9
Employer identification number (EIN)
(Check one.)
✖
1: January, February, March
Baba Rose
Name (not your trade name)
DRAFT AS OF
2: April, May, June
Azalea Accounting Service
Trade name (if any)
3: July, August, September
674 9th Street
Address
4: October, November, December
Number
Street
Suite or room number
Instructions and prior year forms are available
at
Guam
GQ
96912-9691
June 28, 2016
City
State
ZIP code
Foreign country name
Foreign province/county
Foreign postal code
Read the separate instructions before you complete Form 941-SS. Type or print within the boxes.
DO NOT FILE
Part 1:
Answer these questions for this quarter.
Number of employees who received wages, tips, or other compensation for the pay period
1
25
including: Mar. 12 (Quarter 1), June 12 (Quarter 2), Sept. 12 (Quarter 3), or Dec. 12 (Quarter 4)
1
2
3
4
If no wages, tips, and other compensation are subject to social security or Medicare tax
Check and go to line 6.
Column 1
Column 2
.
.
132000
00
5a
Taxable social security wages
× 0.124 =
.
.
5b
Taxable social security tips
× 0.124 =
.
.
132000
00
5c
Taxable Medicare wages & tips
× 0.029 =
Taxable wages & tips subject to
5d
.
.
× 0.009 =
Additional Medicare Tax withholding
.
5e
Add Column 2 from lines 5a, 5b, 5c, and 5d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
5e
.
2265
00
5f
Section 3121(q) Notice and Demand—Tax due on unreported tips (see instructions)
.
.
.
5f
.
6
Total taxes before adjustments. Add lines 5e and 5f .
.
.
.
.
.
.
.
.
.
.
.
.
.
6
.
-
80
7
Current quarter’s adjustment for fractions of cents .
.
.
.
.
.
.
.
.
.
.
.
.
.
7
.
-500
00
8
Current quarter’s adjustment for sick pay .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
8
.
-1000
00
9
Current quarter’s adjustments for tips and group-term life insurance .
.
.
.
.
.
.
.
9
.
10
Total taxes after adjustments. Combine lines 6 through 9
.
.
.
.
.
.
.
.
.
.
.
.
10
.
11
Qualified small business payroll tax credit for increasing research activities. Attach Form 8974
.
11
.
12
Total taxes after adjustments and credits. Subtract line 11 from line 10 .
.
.
.
.
.
.
.
12
Total deposits for this quarter, including overpayment applied from a prior quarter and
13
.
20960
20
13
overpayments applied from Form 941-X, 944-X, or 944-X (SP) filed in the current quarter .
.
.
14
Balance due. If line 12 is more than line 13, enter difference and see instructions
.
.
.
.
.
14
.
15
Overpayment. If line 13 is more than line 12, enter difference
Check one:
Apply to next return.
Send a refund.
You MUST complete both pages of Form 941-SS and SIGN it.
Next
941-SS
For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.
Form
(Rev. 1-2017)
Cat. No. 17016Y

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