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 Page 3

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Form 941-V(SS),
Payment Voucher
Purpose of Form
Caution. Use Form 941-V(SS) when making any
payment with Form 941-SS. However, if you pay an
Complete Form 941-V(SS), Payment Voucher, if you
amount with Form 941-SS that should have been
are making a payment with Form 941-SS, Employer’s
deposited, you may be subject to a penalty. See
QUARTERLY Federal Tax Return. We will use the
Deposit Penalties in section 8 of Pub. 80 (Circular SS).
completed voucher to credit your payment more
Specific Instructions
promptly and accurately, and to improve our service to
you.
Box 1—Employer identification number (EIN). If you
If you have your return prepared by a third party and
do not have an EIN, you may apply for one online. Go to
make a payment with that return, please provide this
IRS.gov and click on the Apply for an EIN Online link. You
payment voucher to the return preparer.
may also apply for an EIN by calling 1-800-829-4933, or
you can fax or mail Form SS-4, Application for Employer
Making Payments With Form 941-SS
Identification Number. If you have not received your EIN
To avoid a penalty, make your payment with Form
by the due date of Form 941-SS, write “Applied For” and
941-SS only if:
the date you applied in this entry space.
• Your net taxes for either the current quarter or the
Box 2—Amount paid. Enter the amount paid with
preceding quarter (line 10) on Form 941-SS are less than
Form 941-SS.
$2,500, you did not incur a $100,000 next-day deposit
Box 3—Tax period. Darken the circle identifying the
obligation during the current quarter, and you are paying
quarter for which the payment is made. Darken only
in full with a timely filed return, or
one circle.
• You are a monthly schedule depositor making a
Box 4—Name and address. Enter your name and
payment in accordance with the Accuracy of Deposits
address as shown on Form 941-SS.
Rule. See section 8 of Pub. 80 (Circular SS), Federal
• Enclose your check or money order payable to the
Tax Guide for Employers in the U.S. Virgin Islands, Guam,
“United States Treasury.” Be sure to enter your EIN,
American Samoa, and the Commonwealth of the
“Form 941-SS,” and the tax period on your check or
Northern Mariana Islands, for details. In this case, the
money order. Do not send cash. Do not staple Form
amount of your payment may be $2,500 or more.
941-V(SS) or your payment to Form 941-SS (or to each
Otherwise, you must make deposits by electronic funds
other).
transfer. See section 8 of Pub. 80 (Circular SS) for deposit
• Detach Form 941-V(SS) and send it with your
instructions. Do not use Form 941-V(SS) to make federal
payment and Form 941-SS to the address in the
tax deposits.
Instructions for Form 941-SS.
Note. You must also complete the entity information
above Part 1 on Form 941-SS.
Detach Here and Mail With Your Payment and Form 941-SS.
941-V(SS)
Payment Voucher
OMB No. 1545-0029
2012
Department of the Treasury
Do not 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.
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.
Quarter
Quarter

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