Form 941-X Draft - Adjusted Employer'S Quarterly Federal Tax Return Or Claim For Refund - 2010 Page 3

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Name (not your trade name)
Employer identification number (EIN)
Correcting quarter
(1, 2, 3, 4)
Correcting calendar year (YYYY)
Part 3: Enter the corrections for this quarter. If any line does not apply, leave it blank.
Column 2
Column 3
Column 4
Column 1
Total corrected
Amount originally
Difference
amount (for ALL
reported or as
(If this amount is a
Tax correction
employees)
previously corrected
negative number,
=
—
(for ALL employees)
use a minus sign.)
6.
Wages, tips and other
Use the amount in Column 1 when
=
you prepare your Forms W-2 or
compensation (from line 2 of
—
.
.
.
Forms W-2c.
Form 941)
7.
Income tax withheld from
=
Copy Column
—
wages, tips, and other
.
.
.
.
3 here
▶
compensation (from line 3 of
Form 941)
8.
Taxable social security wages
(from line 5a, Column 1 of Form
=
—
.
.
.
× .124* =
.
941 or Form 941-SS)
*If you are correcting your employer share only, use .062. See instructions.
9.
Taxable social security tips
=
(from line 5b, Column 1 of Form
—
.
.
.
.
× .124* =
941 or Form 941-SS)
*If you are correcting your employer share only, use .062. See instructions.
10.
Taxable Medicare wages and
=
tips (from line 5c, Column 1 of
—
.
.
.
× .029* =
.
Form 941 or Form 941-SS)
*If you are correcting your employer share only, use .0145. See instructions.
11a.
Number of qualified employees
=
first paid exempt wages/tips
—
this quarter (from line 6a of Form
941 or Form 941-SS)
Number of qualified employees
11b.
=
—
paid exempt wages/tips this
quarter (from line 6b of Form 941
or Form 941-SS)
11c.
Exempt wages/tips paid to
qualified employees this quarter
=
—
.
.
.
.
× .062 =
(from line 6c of Form 941 or Form
941-SS)
12.
Tax adjustments (from lines 7a
through 7c of Form 941 or Form
=
—
Copy Column
.
.
.
.
941-SS)
3 here
▶
Special addition to wages for
13.
=
—
See
.
.
.
.
federal income tax
instructions
14.
Special addition to wages for
=
—
See
.
.
.
.
social security taxes
instructions
15.
Special addition to wages for
=
—
See
.
.
.
.
Medicare taxes
instructions
16.
Combine the amounts on lines 7–15 of Column 4
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
17.
Advance earned income credit
=
—
See
.
.
.
.
(EIC) payments made to
instructions
employees (from Form 941, line 9)
18a.
COBRA premium assistance
=
payments (from line 12a of
—
See
.
.
.
.
instructions
Form 941 or Form 941-SS)
18b.
Number of individuals provided
COBRA premium assistance
=
—
(from line 12b of Form 941 or
Form 941-SS)
18c.
Number of qualified employees
=
paid exempt wages/tips
—
March 19–31 (from line 12c of
Form 941 or Form 941-SS)
18d.
Exempt wages/tips paid to
=
—
qualified employees
.
.
.
.
× .062 =
March 19–31 (from line 12d of
Form 941 or Form 941-SS)
19.
.
Total. Combine the amounts on lines 16–18d of Column 4. Continue on next page .
.
.
.
.
.
.
.
.
.
Next
▶
■
2
941-X
Page
Form
(Rev. 7-2010)

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