Form 941-X - Adjusted Employer'S Quarterly Federal Tax Return Or Claim For Refund - 2017 Page 3

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Name (not your trade name)

Employer identification number (EIN)

Correcting quarter

(1, 2, 3, 4)

Correcting calendar year (YYYY)

Part 4:

Explain your corrections for this quarter.

21.

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 23.

22.

Check here if any corrections involve reclassified workers. Explain on line 23.

23.

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 941 or Form 941-SS and that I have examined this adjusted return or claim, including

accompanying schedules and statements, 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

Print your

name here

title here

Date

Best daytime phone

Check if you are self-employed

Paid Preparer Use Only

Preparer’s name