Form M-941 Wq - Employer'S Quarterly Return Of Income Taxes Withheld
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1M-941
MASSACHUSETTS DEPARTMENT OF REVENUE
EMPLOYER’S QUARTERLY RETURN OF INCOME TAXES WITHHELD
WQ
YOU MUST FILE THIS FORM EVEN THOUGH NO TAX MAY BE DUE.
NUMBER OF EMPLOYEES FROM
FEDERAL IDENTIFICATION NUMBER
BE SURE THIS RETURN COVERS
FOR QTR ENDING
WHOM TAXES WERE WITHHELD:
THE CORRECT PERIOD
Note: An entry must be made in each line. Enter “0,” if applicable.
Check here if EFT payment.
BUSINESS NAME
1. AMOUNT WITHHELD
IF ANY
INFOR-
MATION IS
BUSINESS ADDRESS
2. ADJUSTMENT FOR PRIOR
AMOUNT WITHHELD*
INCORRECT,
SEE
CITY/TOWN
STATE
ZIP
INSTRUC-
3. AMOUNT DUE AFTER ADJUST-
MENT (NOT LESS THAN “0”)
TIONS.
Check if final return and you wish to close your withholding tax account.
4. PENALTIES
5. INTEREST
Return is due with payment on or before the last day of the month following the calendar quarter indicated
6. TOTAL AMOUNT DUE
above. Make check payable to Commonwealth of Massachusetts. Mail to: Mass. Department of Revenue,
(ADD LINES 3, 4 AND 5)
PO Box 7042, Boston, MA 02204.
I declare under the penalties of perjury that this return (including any accompanying schedules and statements)
CHECK HERE IF USING THE BACK OF THIS FORM:
has been examined by me and to the best of my knowledge and belief is a true, correct and complete return.
*Explain any adjustment on reverse or it will be disallowed.
Signature
Title
Date
STATE REASON FOR ADJUSTMENT REQUEST:
LINE 2 ADJUSTMENT INFORMATION
AS REPORTED
CORRECTED
AMOUNT
WITHHELD
ADJUSTMENT
PRIOR PERIOD
AMOUNT
PAID
REPORTED UNDER
FED. IDENT. NO.
REPORTING
PERIOD IN ERROR
38.5M 7/00 00-B02
printed on recycled paper
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