Form 941 - Employer'S Quarterly Federal Tax Return, Form 941-V - Payment Voucher - 2010
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4941 for 2010:
951110
Employer’s QUARTERLY Federal Tax Return
Form
OMB No. 1545-0029
Department of the Treasury — Internal Revenue Service
(Rev. October 2010)
(EIN)
—
Report for this Quarter of 2010
Employer identification number
(Check one.)
Name (not your trade name)
1: January, February, March
2: April, May, June
Trade name (if any)
3: July, August, September
Address
Number
Street
Suite or room number
4: October, November, December
City
State
ZIP code
Read the separate instructions before you complete Form 941. Type or print within the boxes.
Part 1: Answer these questions for this quarter.
Number of employees who received wages, tips, or other compensation for the pay period
1
including: Mar. 12 (Quarter 1), June 12 (Quarter 2), Sept. 12 (Quarter 3), or Dec. 12 (Quarter 4)
1
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2
Wages, tips, and other compensation
2
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3
Income tax withheld from wages, tips, and other compensation
3
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4
If no wages, tips, and other compensation are subject to social security or Medicare tax
Check and go to line 6e.
*Report wages/tips for this quarter,
Column 1
Column 2
.
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including those paid to qualified
5a
Taxable social security wages* .
.
× .124 =
new employees, on lines 5a–5c.
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The social security tax exemption
5b
Taxable social security tips* .
.
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× .124 =
on wages/tips will be figured on
.
.
lines 6c and 6d and will reduce the
5 c
Taxable Medicare wages & tips*
.
× .029 =
tax on line 6e.
.
5d
Add Column 2 line 5a, Column 2 line 5b, and Column 2 line 5c
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5d
See instructions for definitions of
6a
Number of qualified employees first paid exempt wages/tips this quarter
qualified employee and
exempt wages/tips.
6b
Number of qualified employees paid exempt wages/tips this quarter
.
.
Exempt wages/tips paid to qualified employees this quarter
× .062 =
6c
6d
.
6e
Total taxes before adjustments (line 3 + line 5d – line 6d = line 6e) .
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6e
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7a
Current quarter’s adjustment for fractions of cents .
7a
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7b
Current quarter’s adjustment for sick pay .
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7b
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7c
Current quarter’s adjustments for tips and group-term life insurance
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7c
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8
Total taxes after adjustments. Combine lines 6e through 7c .
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8
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9
Advance earned income credit (EIC) payments made to employees
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9
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10
Total taxes after adjustment for advance EIC (line 8 – line 9 = line 10)
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10
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Total deposits, including prior quarter overpayments
11
11
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12a
12a
COBRA premium assistance payments (see instructions)
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12b
Number of individuals provided COBRA premium assistance .
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Complete lines 12c, 12d, and 12e
only for the 2nd quarter of 2010.
12c
Number of qualified employees paid exempt wages/tips March 19–31
.
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12d
Exempt wages/tips paid to qualified employees March 19–31
× .062 =
12e
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13
Add lines 11, 12a, and 12e
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13
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14
Balance due. If line 10 is more than line 13, enter the difference and see instructions
14
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15
Overpayment. If line 13 is more than line 10, enter the difference
Check one:
Apply to next return.
Send a refund.
Next
You MUST complete both pages of Form 941 and SIGN it.
▶
▶
■
941
For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.
Form
(Rev. 10-2010)
Cat. No. 17001Z
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