Form 941-Ss - 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

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Form 941-V(SS),
Payment Voucher
Purpose of Form
Specific Instructions
Box 1—Employer identification number (EIN). If you
Complete Form 941-V(SS) if you’re making a payment
with Form 941-SS. We will use the completed voucher to
don’t have an EIN, you may apply for one online by
credit your payment more promptly and accurately, and
visiting the IRS website at You may also
to improve our service to you.
apply for an EIN by faxing or mailing Form SS-4 to the
IRS. If you haven’t received your EIN by the due date of
Making Payments With Form 941-SS
Form 941-SS, write “Applied For” and the date you
applied in this entry space.
To avoid a penalty, make your payment with Form
941-SS only if:
Box 2—Amount paid. Enter the amount paid with
Form 941-SS.
• Your total taxes for either the current quarter (Form
941-SS, line 12) or the preceding quarter (Form 941-SS,
Box 3—Tax period. Darken the circle identifying the
line 12 (line 10 if the preceding quarter was the fourth
quarter for which the payment is made. Darken only
quarter of 2016)) are less than $2,500, you didn’t incur a
one circle.
$100,000 next-day deposit obligation during the current
Box 4—Name and address. Enter your name and
quarter, and you’re paying in full with a timely filed return;
address as shown on Form 941-SS.
or
• Enclose your check or money order payable to
• You are a monthly schedule depositor making a
“United States Treasury.” Be sure to enter your EIN,
payment in accordance with the Accuracy of Deposits
“Form 941-SS,” and the tax period (“1st Quarter 2017,”
Rule. See section 8 of Pub. 80 for details. In this case, the
“2nd Quarter 2017,” “3rd Quarter 2017,” or “4th Quarter
amount of your payment may be $2,500 or more.
2017”) on your check or money order. Don’t send cash.
Otherwise, you must make deposits by electronic funds
Don’t staple Form 941-V(SS) or your payment to Form
transfer. See section 8 of Pub. 80 for deposit instructions.
941-SS (or to each other).
Don’t use Form 941-V(SS) to make federal tax deposits.
• Detach Form 941-V(SS) and send it with your
Use Form 941-V(SS) when making any
▲
payment and Form 941-SS to the address in the
!
payment with Form 941-SS. However, if you pay
Instructions for Form 941-SS.
an amount with Form 941-SS that should’ve
Note: You must also complete the entity information
CAUTION
been deposited, you may be subject to a
above Part 1 on Form 941-SS.
penalty. See Deposit Penalties in section 8 of Pub. 80.
✁
Detach Here and Mail With Your Payment and Form 941-SS.
▼
▼
941-V(SS)
Payment Voucher
OMB No. 1545-0029
2017
Department of the Treasury
Don’t staple this voucher or your payment to Form 941-SS.
▶
Internal Revenue Service
1 Enter your employer identification
2
Dollars
Cents
number (EIN).
Enter the amount of your payment.
▶
Make your check or money order payable to “United States Treasury”
3 Tax period
4 Enter your business name (individual name if sole proprietor).
1st
3rd
Quarter
Quarter
Enter your address.
2nd
4th
Enter your city, state, and ZIP code or your city, foreign country name, foreign province/county, and foreign postal code.
Quarter
Quarter

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