Schedule R (Form 941) - Allocation Schedule For Aggregate Form 941 Filers - 2017 Page 2
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1
2
3Page
of
Continuation Sheet for Schedule R (Form 941)
Report for calendar year:
(Rev. January 2017)
Check the quarter (same as Form 941):
Employer identification number (EIN)
—
1: January, February, March
2: April, May, June
Name as shown on Form 941
3: July, August, September
Type of filer (check one):
Section 3504 Agent
Certified Professional Employer Organization (CPEO)
4: October, November, December
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
Client’s
Type of wages,
Wages, tips, and
Federal income tax
Total social security
Section 3121(q) Notice
Qualified small business
Total taxes
Total deposits
Employer
tips, and other
other compensation
withheld from wages,
and Medicare taxes
and Demand-Tax due
payroll tax credit for
after adjustments
from Form 941, line 13,
identification
compensation
allocated to the
tips, and other
allocated to the
on unreported tips
increasing research
and credits
plus any payments
number (EIN)
(CPEO Use Only)
listed client EIN from
compensation allocated
listed client EIN from
allocated to the listed
activities allocated to the
allocated to the
made with the return
Form 941, line 2
to the listed client EIN
Form 941, line 5e
client EIN from
listed client EIN from
listed client EIN from
allocated to the
from Form 941, line 3
Form 941, line 5f
Form 941, line 11
Form 941, line 12
listed client EIN
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11
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12
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13
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14
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15
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16
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20
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21
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22
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23
24
Subtotals for
clients. Add lines
1 through 23.
Include the
subtotals from
line 24 on line 12
of Schedule R.
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Schedule R (Form 941) (Rev. 1-2017)
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