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 15

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Exhibit C
Form 941-V
.50 in
Form 941-V,
Payment Voucher
Detach Here and Mail With Your Payment and Form 941.
941-V
Payment Voucher
OMB No. 1545-0029
2017
Department of the Treasury
Don't staple this voucher or your payment to Form 941.
Internal Revenue Service
1 Enter your employer identi cation
2
Dollars
Cents
number (EIN).
Enter the amount of your payment.
Make your check or money order payable to “United States Treasury”
4 Enter your business name (individual name if sole proprietor).
3 Tax Period
1st
3rd
Enter your address.
Quarter
Quarter
2.92 in
2nd
4th
Enter your city, state, and ZIP code or your city, foreign country name, foreign province/county, and foreign postal code.
Quarter
Quarter
.50 in
7.50 in
.50 in
.50 in
13

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