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 3

Name (not your trade name)

Employer identification number (EIN)

Baba Rose

00-3999999

Part 2:

Tell us about your deposit schedule and tax liability for this quarter.

If you are unsure about whether you are a monthly schedule depositor or a semiweekly schedule depositor, see section 8 of Pub. 80.

Line 12 on this return is less than $2,500 or line 12 (line 10 if the prior quarter was the fourth quarter of 2016)

Check one:

on the return for the prior quarter was less than $2,500, and you didn’t incur a $100,000 next-day deposit

obligation during the current quarter. If line 12 (line 10 if the prior quarter was the fourth quarter of 2016) for the

DRAFT AS OF

prior quarter was less than $2,500 but line 12 on this return is $100,000 or more, you must provide a record of your

federal tax liability. If you are a monthly schedule depositor, complete the deposit schedule below; if you are a

semiweekly schedule depositor, attach Schedule B (Form 941). Go to Part 3.

You were a monthly schedule depositor for the entire quarter. Enter your tax liability for each month and

total liability for the quarter, then go to Part 3.

June 28, 2016

Tax liability:

Month 1

Month 2

Month 3

Total liability for quarter

Total must equal line 12.

DO NOT FILE

✖

You were a semiweekly schedule depositor for any part of this quarter. Complete Schedule B (Form 941),

Report of Tax Liability for Semiweekly Schedule Depositors, and attach it to Form 941-SS.

Part 3:

Tell us about your business. If a question does NOT apply to your business, leave it blank.

If your business has closed or you stopped paying wages .

Check here, and

enter the final date you paid wages

If you are a seasonal employer and you don’t have to file a return for every quarter of the year .

Check here.

Part 4:

May we speak with your third-party designee?

Do you want to allow an employee, a paid tax preparer, or another person to discuss this return with the IRS? See the

instructions for details.

Yes.

Designee’s name and phone number

Select a 5-digit Personal Identification Number (PIN) to use when talking to IRS.

No.

Part 5:

Sign here. You MUST complete both pages of Form 941-SS and SIGN it.

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge

and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Print your

Sign your

name here

Print your

title here

Date

Best daytime phone

Paid Preparer Use Only

Check if you are self-employed .

Preparer’s name

PTIN

Preparer’s signature