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Type of Submission

If no Forms W-2 (Copy A) were filed by you, write

“-0-” in Column B, “Amount you reported to SSA

Check the appropriate box to show whether this form is

for the tax year.”

CAUTION

the “Original” Schedule D (Form 941) for a specific

If you are filing for one transaction only, stop here. If

transaction or corrects (mark “Corrected”) a Schedule D

you are filing for more than one transaction, go to Part 3.

(Form 941) you previously submitted.

Part 3: Fill this part out ONLY if you

Part 1: Answer these background

are filing more than one Schedule D

questions

(Form 941) for any calendar year

1. Check the appropriate box to explain the type of

transaction for which you are submitting Schedule D

If you are filing only one Schedule D (Form 941) for the

(Form 941). See Types of Mergers and Acquisitions on

calendar year, leave this part blank.

page 1 for details.

When more than one statutory merger, consolidation,

File Schedule D (Form 941) after either:

or acquisition occurs during a calendar year, file a

a. A statutory merger or consolidation (Check whether

separate Schedule D (Form 941) for each transaction.

you are an acquired corporation or a surviving

Complete Part 3 for each transaction. For instance, if you

corporation.), or

have 11 different transactions in a calendar year, you

b. An acquisition for which you are using the alternate

need to file 11 different Schedules D (Form 941). Part 2

procedure under Rev. Proc. 2004-53. (Check whether

would be the same for each schedule. Part 3 would show

you are a predecessor or a successor.)

one of the 11 transactions. For example, the amount

2. Fill in the effective date of the transaction in the

entered in Part 2 on line 4 for Column C should equal the

box. Make sure you write the month, day, and year in this

total of all 11 entries in Part 3 on line 10 for Column C.

format: MM/DD/YYYY. The year must be the same as the

Line 9. Show the number of schedules you are filing for

calendar year you write in the box at the top of the

the year and identify which schedule this is. For example,

schedule.

if you had three different transactions in a calendar year

3. Fill in the contact information about the OTHER

and you are filing a Schedule D (Form 941) to describe

PARTY in the transaction by including the other party’s

the second transaction, fill in “2” and “3” so the sentence

EIN, name, trade name (doing business as or d/b/a),

reads: “This is schedule 2 of 3. ”

complete address, and phone number. Verify the other

Lines 10–14. For purposes of Part 3, Columns A and B,

party’s EIN to make sure it is correct.

the term “employees affected by the transaction reported

on this Schedule D” means those employees who

Part 2: Tell us about the

received wages that were reported on Forms 941 filed by

one employer but whose wages were reported on Form

discrepancies with your returns

W-2 (Copy A) filed by another employer as a result of this

Lines 4–8. Gather your information about the social

particular transaction. Report the totals for social security

wages, Medicare wages and tips, social security tips,

security wages, Medicare wages and tips, social security

federal income tax withheld, and advance earned income

tips, federal income tax withheld, and advance earned

credit (EIC) payments (for tax years ending before

income credit (EIC) payments (for tax years ending

before January 1, 2011) you reported. When entering

January 1, 2011).

money amounts from your Forms 941 and W-2 (Copy A)

In Column A, fill in the amount you reported to the IRS

on lines 4–14, you may round to the nearest dollar. Do

for the tax year for employees affected by the transaction

not show dollar signs but do use commas as appropriate.

reported on this Schedule D (Form 941) for each of the

Show an amount (even if it is zero) for each column of a

items. Add the totals from all your Forms 941, as

line.

corrected by any Forms 941-X, and write your answers

on the appropriate lines.

In Column A, fill in the amount you reported to the IRS

for the tax year for each of the items. Add the totals from

In Column B, fill in the amount you reported to SSA for

all Forms 941, as corrected by any Forms 941-X,

the tax year for employees affected by the transaction

Adjusted Employer’s QUARTERLY Federal Tax Return

reported on this Schedule D (Form 941) for each of the

or Claim for Refund, and write your answers on the

items. Add the totals from all Forms W-2 (Copy A), as

appropriate lines.

corrected by any Forms W-2c (Copy A), and write your

answers on the appropriate lines.

In Column B, fill in the amount you reported to SSA for

Calculate the differences between the entries in the

each of the items. Add the totals from all Forms W-2

columns:

(Copy A), as corrected by any Forms W-2c, Corrected

Wage and Tax Statement (Copy A), and write your

Column A

answers on the appropriate lines.

– Column B

Calculate the differences between the entries in the

Column C

columns:

Column A

Enter any negative result in parentheses, if possible.

– Column B

For example, if line 12, Column A is “-0-” and line 12,

Column C

Column B is “6,000,” write “(6,000)” on line 12, Column

If no Forms W-2 (Copy A) were filed by you, write

Enter any negative result in parentheses, if possible.

“-0-” in Column B, “Amount you reported to SSA

For example, if line 6, Column A is “-0-” and line 6,

for the tax year.”

Column B is “6,000,” write “(6,000)” on line 6, Column C.

CAUTION

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Instructions For Schedule D (Form 941) - Report Of Discrepancies Caused By Acquisitions, Statutory Mergers, Or Consolidations Page 3

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