Schedule B (Form 941) - Report Of Tax Liability For Semiweekly Schedule Depositors - 2009

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Schedule B (Form 941):

960309

Report of Tax Liability for Semiweekly Schedule Depositors

OMB No. 1545-0029

(Rev.

February 2009)

Department of the Treasury – Internal Revenue Service

Report for this Quarter

1:

Employer identification number

January, February, March

2:

Name (not your trade name)

April, May, June

3:

Calendar year

July, August, September

(Also check quarter)

4:

Use this schedule to show your TAX LIABILITY for the quarter; DO NOT use it to show your deposits. When you file this form with Form 941 or Form 941-SS, DO NOT change your tax liability by adjustments

October, November, December

reported on any Forms 941-X. You must fill out this form and attach it to Form 941 or Form 941-SS if you area semiweekly schedule depositor or became one because your accumulated tax liability on any

day was $100,000 or more. Write your daily tax liability on the numbered space that corresponds to the date wages were paid. See Section 11 in Pub. 15 (Circular E), Employer’s Tax Guide, for details.

Month 1

Tax liability for Month 1

1

9

17

25

2

10

18

26

3

11

19

27

4

12

20

28

5

13

21

29

6

14

22

30

7

15

23

31

8

16

24

Month 2

Tax liability for Month 2

1

9

17

25

2

10

18

26

3

11

19

27

4

12

20

28

5

13

21

29

6

14

22

30

7

15

23

31

8

16

24

Month 3

Tax liability for Month 3

1

9

17

25

2

10

18

26

3

11

19

27

4

12

20

28

5

13

21

29

6

14

22

30

7

15

23

31

Total liability for the quarter

8

16

24

Fill in your total liability for the quarter (Month 1 + Month 2 + Month 3)

Total must equal line 10 on Form 941 or Form 941-SS.

For Paperwork Reduction Act Notice, see separate inst uctions.

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Schedule B (Form 941)

5305 / L941B

Rev.

6

-20

11