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 - 2012

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941-SS for 2012:
Employer’s QUARTERLY Federal Tax Return
Form
American Samoa, Guam, the Commonwealth of the Northern
(Rev. January 2012)
Mariana Islands, and the U.S. Virgin Islands
Department of the Treasury — Internal Revenue Service
OMB No. 1545-0029
(EIN)
Report for this Quarter of 2012
Employer identification number
(Check one.)
Name (not your trade name)
1: January, February, March
2: April, May, June
Trade name (if any)
3: July, August, September
Address
4: October, November, December
Number
Street
Suite or room number
Prior-year forms are available at
City
State
ZIP code
Read the separate instructions before you complete Form 941-SS. Type or print within the boxes.
Part 1:
Answer these questions for this quarter.
Number of employees who received wages, tips, or other compensation for the pay period
1
including: Mar. 12 (Quarter 1), June 12 (Quarter 2), Sept. 12 (Quarter 3), or Dec. 12 (Quarter 4)
1
2
3
4
If no wages, tips, and other compensation are subject to social security or Medicare tax
Check and go to line 6.
Column 1
Column 2
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5a
Taxable social security wages
× .104 =
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5b
Taxable social security tips
× .104 =
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5c
Taxable Medicare wages & tips
× .029 =
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5d
Add Column 2 line 5a, Column 2 line 5b, and Column 2 line 5c
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5d
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5e
Section 3121(q) Notice and Demand—Tax due on unreported tips (see instructions) .
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5e
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6
Total taxes before adjustments (add lines 5d and 5e) .
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6
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7
Current quarter’s adjustment for fractions of cents .
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7
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8
Current quarter’s adjustment for sick pay .
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8
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9
Current quarter’s adjustments for tips and group-term life insurance .
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9
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10
Total taxes after adjustments. Combine lines 6 through 9
10
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11
Total deposits for this quarter, including overpayment applied from a prior quarter and
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overpayment applied from Form 941-X or Form 944-X .
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11
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12a
COBRA premium assistance payments (see instructions)
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. 12a
12b
Number of individuals provided COBRA premium assistance .
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13
Add lines 11 and 12a .
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13
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Balance due. If line 10 is more than line 13, enter difference and see instructions
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14
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15
Overpayment. If line 13 is more than line 10, enter difference
Check one:
Apply to next return.
Send a refund.
You MUST complete both pages of Form 941-SS and SIGN it.
Next
941-SS
For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.
Form
(Rev. 1-2012)
Cat. No. 17016Y

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