Form 944-X - Adjusted Employer'S Annual Federal Tax Return Or Claim For Refund - 2015 Page 2
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1
2
3
4Name (not your trade name)
Employer identification number (EIN)
Correcting 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 1
Column 2
Column 3
Column 4
Amount originally
Difference
Total corrected
reported or as
(If this amount is a
=
—
amount (for ALL
Tax correction
previously corrected
negative number,
employees)
(for ALL employees)
use a minus sign.)
6.
Wages,
tips
and
other
Use the amount in Column 1
=
—
when you prepare your Forms
compensation (Form 944, line 1)
.
.
.
W-2 or Forms W-2c.
Copy
Federal income tax withheld from
7.
=
Column 3
—
wages,
tips,
and
other
.
.
.
.
here
▶
compensation (Form 944, line 2)
8.
Taxable social security wages
=
=
× .124*
—
(Form 944 or Form 944-SS, line
.
.
.
.
4a, Column 1)
*If you are correcting a 2011 or 2012 return, use .104. If you are correcting your employer share only, use .062. See instructions.
9.
Taxable social security tips
=
=
× .124*
—
(Form 944 or Form 944-SS, line
.
.
.
.
4b, Column 1)
*If you are correcting a 2011 or 2012 return, use .104. If you are correcting your employer share only, use .062. See instructions.
10.
Taxable Medicare wages & tips
=
=
× .029*
—
(Form 944 or Form 944-SS, line
.
.
.
.
4c, Column 1)
*If you are correcting your employer share only, use .0145. See instructions.
11.
Taxable wages & tips subject to
=
=
× .009*
—
Additional Medicare Tax withholding
.
.
.
.
(Form 944 line 4d, only for years
*Certain wages & tips reported in Column 3 should not be multiplied by .009. See instructions.
beginning after December 31, 2012)
Copy
12.
Tax adjustments (Form 944 or
=
Column 3
—
Form 944-SS, line 6)
.
.
.
.
here
▶
13.
Special addition to wages for
See
=
—
federal income tax
instructions
.
.
.
.
14.
Special addition to wages for
See
=
—
social security taxes
instructions
.
.
.
.
15.
Special addition to wages for
See
=
—
Medicare taxes
instructions
.
.
.
.
16.
Special addition to wages for
See
=
—
Additional Medicare Tax
instructions
.
.
.
.
17.
Subtotal. Combine the amounts on lines 7–16 of Column 4
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
18 a. COBRA premium assistance
See
=
—
instructions
payments (see instructions)
.
.
.
.
18 b. Number of individuals provided
—
=
COBRA premium assistance
(see instructions)
19.
Total. Combine the amounts on lines 17 and 18a of Column 4 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
If line 19 is less than zero:
• If you checked line 1, this is the amount you want applied as a credit to your Form 944 for the tax period in which you are filing this form
(If you are currently filing a Form 941 or Form 941-SS, Employer’s QUARTERLY Federal Tax Return, see the instructions.)
• If you checked line 2, this is the amount you want refunded or abated.
If line 19 is more than zero, this is the amount you owe. Pay this amount by the time you file this return. For information on how to pay,
see Amount you owe in the instructions.
Next
▶
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2
944-X
Page
Form
(Rev. 2-2015)
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