Publication 4436 - General Rules And Specifications For Substitute Form 941, Schedule B (Form 941), Schedule D (Form 941), Schedule R (Form 941), And Form 8974 Page 13
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21Section 1.12 – Exhibits
Exhibit A
Form 941
Page 1
.50 in
941 for 2017:
Employer’s QUARTERLY Federal Tax Return
950117
Form
OMB No. 1545-0029
(Rev. January 2017)
Department of the Treasury — Internal Revenue Service
Report for this Quarter of 2017
—
Employer identification number (EIN)
.27 in
(Check one.)
5.00 in
1: January, February, March
Name (not your trade name)
3.50 in
2.50 in
2: April, May, June
Trade name (if any)
3.80 in
3: July, August, September
1.88 in
4.30 in
Address
4: October, November, December
Number
Street
Suite or room number
Instructions and prior year forms are
available at
2.60 in
.50 in
1.00 in
City
State
ZIP code
2.15 in
2.00 in
1.20 in
.90 in
Foreign country name
Foreign province/county
Foreign postal code
Read the separate instructions before you complete Form 941. Type or print within the boxes.
Answer these questions for this quarter.
Part 1:
1
Number of employees who received wages, tips, or other compensation for the pay period
.20 in
including: Mar. 12 (Quarter 1), June 12 (Quarter 2), Sept. 12 (Quarter 3), or Dec. 12 (Quarter 4)
1
.50 in
.50 in
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2
Wages, tips, and other compensation
.
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2
.
3
Federal income tax withheld from wages, tips, and other compensation .
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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
.
.
5a
Taxable social security wages .
.
× 0.124 =
.
.
1.70 in
5b
Taxable social security tips .
.
.
× 0.124 =
.
.
5c
Taxable Medicare wages & tips.
.
× 0.029 =
Taxable wages & tips subject to
5d
.
.
× 0.009 =
1.30 in
Additional Medicare Tax withholding
.
5e
Add Column 2 from lines 5a, 5b, 5c, and 5d
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5e
1.80 in
.
5f
Section 3121(q) Notice and Demand—Tax due on unreported tips (see instructions)
5f
.
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6
Total taxes before adjustments. Add lines 3, 5e, and 5f .
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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
Qualified small business payroll tax credit for increasing research activities. Attach Form 8974
11
.
12
Total taxes after adjustments and credits. Subtract line 11 from line 10 .
.
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12
Total deposits for this quarter, including overpayment applied from a prior quarter and
13
.
13
overpayments applied from Form 941-X, 941-X (PR), 944-X, or 944-X (SP) filed in the current quarter
.
14
Balance due. If line 12 is more than line 13, enter the difference and see instructions
.
.
.
14
3.70 in
.
15
Overpayment. If line 13 is more than line 12, enter the difference
Check one:
Apply to next return.
Send a refund.
.22 in
Next
You MUST complete both pages of Form 941 and SIGN it.
941
For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.
Form
(Rev. 1-2017)
Cat. No. 17001Z
11
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