Form M-941a - Employer'S Annual Return Of Income Taxes Withheld
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1M-941A
MASSACHUSETTS DEPARTMENT OF REVENUE
EMPLOYER’S ANNUAL RETURN OF INCOME TAXES WITHHELD
A
NUMBER OF EMPLOYEES FROM
YOU MUST FILE THIS FORM EVEN THOUGH NO TAX MAY BE DUE.
WHOM TAXES WERE WITHHELD:
FEDERAL IDENTIFICATION NUMBER
BE SURE THIS RETURN COVERS
FOR YEAR
THE CORRECT PERIOD
Note: An entry must be made in each line. Enter “0,” if applicable.
Check here if EFT payment.
IF INCORRECT, SEE INSTRUCTIONS. DO NOT ALTER.
1. AMOUNT WITHHELD
BUSINESS NAME
IF ANY
INFOR-
2. ADJUSTMENT FOR PRIOR
BUSINESS ADDRESS
AMOUNT WITHHELD*
MATION IS
INCORRECT,
SEE
3. AMOUNT DUE AFTER ADJUST-
CITY/ TOWN
STATE
ZIP
MENT (NOT LESS THAN “0”)
INSTRUC-
TIONS.
Check if final return and you wish to close your withholding tax account.
4. PENALTIES
5. INTEREST
6. TOTAL AMOUNT DUE
Return is due with payment on or before the 31st day of January following the year indicated above. Make check
(ADD LINES 3, 4 AND 5)
payable to Commonwealth of Mass. Mail to: Mass. Dept. of Revenue, 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. Adjustment
must be from immediate prior period.
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
4.5M 7/00 00-B02
printed on recycled paper
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