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Form 941 - Employers Quarterly Federal Tax Return, Schedule B (Form 941): Report Of Tax Liability For Semiweekly Schedule Depositors - 2010 Page 2

9 5 0 2 1 0

Name (not your trade name)

Employer Identification Number (EIN)

Sample Company

12-3456789

Part 2: Tell us about your deposit schedule and tax liability for this quarter.

If you are unsure about whether you are a monthly schedule depositor or a semiweekly schedule depositor, see Pub. 15

(Circular E), section 11.

Write the state abbreviation for the state where you made your deposits OR write ''MU'' if you made your

deposits in multiple states.

Line 10 on this return is less than $2,500 or line 10 on the return for the preceding quarter was less than $2,500, and you

17 Check one:

did not incur a $100,000 next-day deposit obligation during the current quarter.

Go to Part 3.

You were a monthly schedule depositor for the entire quarter. Enter your tax liability

for each month. Then go to Part 3.

Tax liability: Month 1

Month 2

Month 3

Total liability for quarter

Total must equal line 10.

You were a semiweekly schedule depositor for any part of this quarter. Complete Schedule B (Form 941):

Report of Tax Liability for Semiweekly Schedule Depositors, and attach it to Form 941.

Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank.

18 If your business has closed or you stopped paying wages .

Check here, and

enter the final date you paid wages

19 If you are a seasonal employer and you do not have to file a return for every quarter of the year .

Check here.

Part 4: May we speak with your third-party designee?

Do you want to allow an employee, a paid tax preparer, or another person to discuss this return with the IRS? See the instructions

for details.

Yes. Designee's name and phone number

Select a 5-digit Personal Identification Number (PIN) to use when talking to IRS.

No.

Part 5: Sign here. You MUST complete both pages of Form 941 and SIGN it.

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge

and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Print your

name here

Sign your

Print your

name here

title here

Date

Best daytime phone

Paid preparer's use only

Check if you are self-employed .

Preparer's

Preparer's name