Form 944-X - Adjusted Employer'S Annual Federal Tax Return Or Claim For Refund - 2015 Page 3
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1
2
3
4Name (not your trade name)
Employer identification number (EIN)
Correcting Calendar Year (YYYY)
Part 4:
Explain your corrections for the calendar year you are correcting.
20.
Check here if any corrections you entered on a line include both underreported and overreported amounts.
Explain both your underreported and overreported amounts on line 22.
21.
Check here if any corrections involve reclassified workers. Explain on line 22.
22.
You must give us a detailed explanation of how you determined your corrections. See the instructions.
Part 5:
Sign here. You must complete all three pages of this form and sign it.
Under penalties of perjury, I declare that I have filed an original Form 944 or Form 944-SS and that I have examined this adjusted return or claim
and any schedules or statements that are attached, and to the best of my knowledge and belief, they are 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
name here
Print your
title here
/
/
Date
Best daytime phone
Paid Preparer Use Only
Check if you are self-employed
.
.
Preparer’s name
PTIN
/
/
Preparer’s signature
Date
Firm’s name (or yours if
EIN
self-employed)
Address
Phone
City
State
ZIP code
3
944-X
Page
Form
(Rev. 2-2015)
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