Form 943-X - Adjusted Employer'S Annual Federal Tax Return For Agricultural Employees Or Claim For Refund Page 2

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Name (not your trade name)
Employer Identification Number (EIN)
Calendar Year (YYYY)
Part 3:
Enter the corrections for the calendar year you are correcting. If any line does not apply, leave it blank.
Column 2
Column 3
Column 4
Column 1
Amount originally
Difference
=
Total corrected
reported or as
(If this amount is a
—
amount (for ALL
previously corrected
negative number, use
employees)
(for ALL employees)
a minus sign.)
Tax correction
Total wages subject to social
6.
=
—
× .124* =
security tax
.
.
.
.
(from line 2 of Form 943)
*If you are correcting a 2011 return , use .104. If you are correcting your
employer share only, use .062. See instructions.
Total wages subject to
7.
=
—
Medicare tax
× .029* =
.
.
.
.
(from line 4 of Form 943)
*If you are correcting your employer share only, use .0145. See
instructions.
8.
Federal income tax withheld
=
Copy Column
—
.
.
.
.
3 here
▶
(from line 6 of Form 943)
*Complete lines
9a. Number of qualified
=
—
9a and 9b only
employees paid exempt
for corrections
wages April 1 – December 31,
to the 2010
Form 943.
2010 (from line 7a of Form 943)*
9b. Exempt wages paid to
=
—
.
.
.
× .062 =
.
qualified employees April 1 –
December 31, 2010 (from line
7b of Form 943)*
Tax adjustments
=
10.
—
See
.
.
.
.
instructions
(from line 8 of Form 943)
Special addition to wages for
11.
=
See
—
.
.
.
.
instructions
federal income tax
Special addition to wages for
=
12.
See
—
.
.
.
.
instructions
social security taxes
Special addition to wages for
=
13.
—
See
.
.
.
.
instructions
Medicare taxes
14.
Subtotal: Combine the amounts in lines 6–13 of Column 4 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
15.
Advance earned income
=
See
—
credit (EIC) payments made
.
.
.
.
instructions
to employees (from line 10 of
Form 943; only for years ending
before January 1, 2011)
16a. COBRA premium assistance
=
—
See
payments (from line 11a of Form
.
.
.
.
instructions
943 (line 13a for years ending
before January 1, 2011))
16b. Number of individuals provided
=
—
*Complete lines
COBRA premium assistance (from
16c and 16d
line 11b of Form 943 (line 13b for
only for
corrections to
years ending before January 1, 2011))
the 2010
16c. Number of qualified
Form 943.
=
—
employees paid exempt
wages March 19–31, 2010
(from line 13c of Form 943)*
16d. Exempt wages paid to
=
—
.
.
.
× .062 =
.
qualified employees March
19–31, 2010 (from line 13d of
Form 943)*
17.
Total. Combine the amounts in lines 14–16d of Column 4. Continue to next page.
.
.
.
.
.
.
.
.
.
.
.
.
Next
▶
■
2
943-X
Page
Form
(Rev. 2-2012)

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