Form 941-X - Adjusted Employer'S Quarterly Federal Tax Return Or Claim For Refund - 2012
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4941-X:
Adjusted Employer's QUARTERLY Federal Tax Return or Claim for Refund
Form
Department of the Treasury — Internal Revenue Service
(Rev. April 2012)
OMB No. 1545-0029
Return You Are Correcting ...
—
Employer identification number (EIN)
Check the type of return you are correcting:
941
Name (not your trade name)
941-SS
Trade name (if any)
Check the ONE quarter you are correcting:
Address
1: January, February, March
Number
Street
Suite or room number
2: April, May, June
City
State
ZIP code
3: July, August, September
Read the instructions before completing this form. Use this form to correct errors you made on
4: October, November, December
Form 941 or Form 941-SS. Use a separate Form 941-X for each quarter that needs correction.
Type or print within the boxes. You MUST complete all three pages. Do not attach this form to
Enter the calendar year of the quarter
Form 941 or Form 941-SS.
you are correcting:
Part 1:
Select ONLY one process.
(YYYY)
1. Adjusted employment tax return. Check this box if you underreported amounts. Also
check this box if you overreported amounts and you would like to use the adjustment
Enter the date you discovered errors:
process to correct the errors. You must check this box if you are correcting both
underreported and overreported amounts on this form. The amount shown on line 21, if
less than zero, may only be applied as a credit to your Form 941, Form 941-SS, or Form
/
/
944 for the tax period in which you are filing this form.
(MM / DD / YYYY)
2. Claim. Check this box if you overreported amounts only and you would like to use the
claim process to ask for a refund or abatement of the amount shown on line 21. Do not
check this box if you are correcting ANY underreported amounts on this form.
Part 2:
Complete the certifications.
3. I certify that I have filed or will file Forms W-2, Wage and Tax Statement, or Forms W-2c, Corrected Wage and Tax Statement,
as required.
Note. If you are correcting underreported amounts only, go to Part 3 on page 2 and skip lines 4 and 5.
4. If you checked line 1 because you are adjusting overreported amounts, check all that apply. You must check at least one box.
I certify that:
a.
I repaid or reimbursed each affected employee for the overcollected federal income tax for the current year and the overcollected
social security and Medicare taxes for current and prior years. For adjustments of employee social security and Medicare taxes
overcollected in prior years, I have a written statement from each employee stating that he or she has not claimed (or the claim
was rejected) and will not claim a refund or credit for the overcollection.
b.
The adjustments of social security tax and Medicare tax are for the employer’s share only. I could not find the affected employees
or each employee did not give me a written statement that he or she has not claimed (or the claim was rejected) and will not claim
a refund or credit for the overcollection.
c.
The adjustment is for federal income tax, social security tax, and Medicare tax that I did not withhold from employee wages.
5. If you checked line 2 because you are claiming a refund or abatement of overreported employment taxes, check all that apply.
You must check at least one box.
I certify that:
a.
I repaid or reimbursed each affected employee for the overcollected social security and Medicare tax. For claims of employee
social security and Medicare tax overcollected in prior years, I have a written statement from each employee stating that he or she
has not claimed (or the claim was rejected) and will not claim a refund or credit for the overcollection.
b.
I have a written consent from each affected employee stating that I may file this claim for the employee’s share of social security
and Medicare tax. For refunds of employee social security and Medicare tax overcollected in prior years, I also have a written
statement from each employee stating that he or she has not claimed (or the claim was rejected) and will not claim a refund or
credit for the overcollection.
c.
The claim for social security tax and Medicare taxes is for the employer’s share only. I could not find the affected employees; or
each employee did not give me a written consent to file a claim for the employee’s share of social security and Medicare taxes; or
each employee did not give me a written statement that he or she has not claimed (or the claim was rejected) and will not claim a
refund or credit for the overcollection.
d.
The claim is for federal income tax, social security tax, and Medicare tax that I did not withhold from employee wages.
Next
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941-X
For Paperwork Reduction Act Notice, see the separate instructions.
Form
(Rev. 4-2012)
IRS.gov/form941x
Cat. No. 17025J
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