Form 943-X - Adjusted Employer'S Annual Federal Tax Return For Agricultural Employees Or Claim For Refund Page 3

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Name (not your trade name)

Employer identification number (EIN)

Calendar Year (YYYY)

Part 3:

Continued

20.

Total. Amount from line 19 on page 2 .

If line 20 is less than zero:

• If you checked line 1, this is the amount you want applied as a credit to your Form 943 for the tax period in which you are filing

this form.

• If you checked line 2, this is the amount you want refunded or abated.

If line 20 is more than zero, this is the amount you owe. Pay this amount when you file this return. For information on how to

pay, see Amount you owe in the instructions for line 20.

Part 4:

Explain your corrections for the calendar year you are correcting.

Check here if any corrections you entered on a line include both underreported and overreported amounts.

21.

Explain both your underreported and overreported amounts on line 23.

22.

Check here if any corrections involve reclassified workers. Explain on line 23.

23.

You must give us a detailed explanation for how you determined your corrections. See the separate instructions.

Part 5:

Sign here. You must complete all three pages of this form and sign it.

Under penalties of perjury, I declare that I have filed an original Form 943 and that I have examined this adjusted return or claim and any schedules or

statements that are attached, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer)

is based on all information of which preparer has any knowledge.

✗

Print your

name here

Sign your

name here

Print your

title here

Date

Best daytime phone

Paid Preparer Use Only

Check if you are self-employed