Form 941-X - Adjusted Employer'S Quarterly Federal Tax Return Or Claim For Refund - 2017 Page 2
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1
2
3
4Name (not your trade name)
Employer identification number (EIN)
Correcting quarter
(1, 2, 3, 4)
Correcting calendar year (YYYY)
Part 3:
Enter the corrections for this quarter. If any line does not apply, leave it blank.
Column 2
Column 3
Column 4
Column 1
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
=
—
.
.
.
compensation (Form 941, line 2)
prepare your Forms W-2 or Forms W-2c.
7.
Federal income tax withheld
Copy Column
=
from wages, tips, and other
—
.
.
.
.
3 here
▶
compensation (Form 941, line 3)
Taxable social security wages
8.
=
—
(Form 941 or 941-SS, line 5a,
.
.
.
.
× .124* =
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.
Taxable social security tips (Form
9.
=
—
941 or 941-SS, line 5b, Column 1)
.
.
.
.
× .124* =
*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 and tips
=
—
(Form 941 or 941-SS, line 5c, Column 1)
.
.
.
.
× .029* =
*If you are correcting your employer share only, use .0145. See instructions.
11.
Taxable wages & tips subject to
=
—
Additional Medicare Tax withholding
.
.
.
.
× .009* =
(Form 941 or 941-SS, line 5d; only for
*Certain wages and tips reported in Column 3 should not be multiplied by .009. See instructions.
quarters beginning after December 31, 2012)
12.
Section 3121(q) Notice and Demand —
=
Copy Column
—
.
.
.
.
Tax due on unreported tips
3 here
▶
(Form 941 or 941-SS, line 5f (line 5e for
quarters ending before January 1, 2013))
13.
Tax adjustments (Form 941 or
=
—
Copy Column
.
.
.
.
941-SS, lines 7–9)
3 here
▶
14.
Special addition to wages for
=
—
See
.
.
.
.
federal income tax
instructions
15.
Special addition to wages for
=
—
See
.
.
.
.
social security taxes
instructions
16.
Special addition to wages for
=
—
See
.
.
.
.
Medicare taxes
instructions
17.
Special addition to wages for
=
—
See
.
.
.
.
Additional Medicare Tax
instructions
.
18.
Combine the amounts on lines 7–17 of Column 4
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
19a.
COBRA premium assistance
=
—
See
.
.
.
.
payments (see instructions)
instructions
19b.
Number of individuals provided
=
—
COBRA premium assistance
(see instructions)
.
20.
Total. Combine the amounts on lines 18 and 19a of Column 4 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
If line 20 is less than zero:
• If you checked line 1, this is the amount you want applied as a credit to your Form 941 for the tax period in which you are filing this
form. (If you are currently filing a Form 944, Employer’s ANNUAL Federal Tax Return, see the instructions.)
• If you checked line 2, this is the amount you want refunded or abated.
If line 20 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
941-X
Page
Form
(Rev. 4-2015)
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