Form 941 (Rev. April 2009) 101030
2015-10-30
: Pdf 101030 101030 Forms
Open the PDF directly: View PDF 
.
Page Count: 4
941 for 2009:
(Rev. April 2009)
OMB No. 1545-0029
Employer’s QUARTERLY Federal Tax Return
Department of the Treasury — Internal Revenue Service
950109
Employer identification number
Name (not your trade name)
Trade name (if any)
Address
Number
Street
Suite or room number
City
State
ZIP code
Read the separate instructions before you complete Form 941. Type or print within the boxes.
Report for this Quarter of 2009
(Check one.)
1: January, February, March
2: April, May, June
3: July, August, September
4: October, November, December
Form
—
(EIN)
1
2
3
4
5
6
7
8
9
10
11
14
15
5a
5b
5c
5d
7d
Number of employees who received wages, tips, or other compensation for the pay period
including: Mar. 12 (Quarter 1), June 12 (Quarter 2), Sept. 12 (Quarter 3), Dec. 12 (Quarter 4)
Wages, tips, and other compensation
Income tax withheld from wages, tips, and other compensation
If no wages, tips, and other compensation are subject to social security or Medicare tax Check and go to line 6.
Taxable social security and Medicare wages and tips:
Column 1
Column 2
Taxable social security wages
3 .124 =
Taxable social security tips
Taxable Medicare wages & tips
3 .029 =
Total social security and Medicare taxes (Column 2, lines 5a + 5b + 5c = line 5d)
Total taxes before adjustments (lines 3 + 5d = line 6)
CURRENT QUARTER’S ADJUSTMENTS, for example, a fractions of cents adjustment.
See the instructions.
Current quarter’s fractions of cents
Current quarter’s sick pay
Current quarter’s adjustments for tips and group-term life insurance
TOTAL ADJUSTMENTS. Combine all amounts on lines 7a through 7c
Total taxes after adjustments. Combine lines 6 and 7d
Advance earned income credit (EIC) payments made to employees
Total taxes after adjustment for advance EIC (line 8 – line 9 = line 10)
Total deposits for this quarter, including overpayment applied from a
prior quarter and overpayment applied from Form 941-X or
Form 944-X
Balance due. If line 10 is more than line 13, write the difference here
Overpayment. If line 13 is more than line 10, write the difference here
Check one
Apply to next return.
Send a refund.
Next
3 .124 =
7a
7b
7c
1
2
3
6
8
9
10
14
5d
7d
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
©
For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.
Cat. No. 17001Z
Form 941 (Rev. 4-2009)
©You MUST complete both pages of Form 941 and SIGN it.
For information on how to pay, see the instructions.
Part 1: Answer these questions for this quarter.
.
.
12a
COBRA premium assistance payments (see instructions)
13
Add lines 11 and 12a 13
Number of individuals provided COBRA premium
assistance reported on line 12a
12b
enter the final date you paid wages .
If your business has closed or you stopped paying wages
950209
Part 2: Tell us about your deposit schedule and tax liability for this quarter.
.
.
.
If you are unsure about whether you are a monthly schedule depositor or a semiweekly schedule depositor, see Pub. 15
(Circular E), section 11.
16
17
18
19
Write the state abbreviation for the state where you made your deposits OR write “MU” if you made your
deposits in multiple states.
Check one:
Line 10 is less than $2,500. Go to Part 3.
You were a monthly schedule depositor for the entire quarter. Enter your tax liability
for each month. Then go to Part 3.
.
Tax liability:
Month 1
Month 2
Month 3
Total liability for quarter
Total must equal line 10.
You were a semiweekly schedule depositor for any part of this quarter. Complete Schedule B (Form 941):
Report of Tax Liability for Semiweekly Schedule Depositors, and attach it to Form 941.
Check here, and
If you are a seasonal employer and you do not have to file a return for every quarter of the year
Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank.
Check here.
Preparer’s signature
Firm’s name (or yours
if self-employed)
Address
EIN
ZIP code
Preparer’s
SSN/PTIN
Check if you are self-employed
Date
/ /
Phone
( ) –
Form 941 (Rev. 4-2009)
Page 2
/ /
Name (not your trade name)
Employer identification number (EIN)
Do you want to allow an employee, a paid tax preparer, or another person to discuss this return with the IRS? See the instructions
for details.
Yes.
Designee’s name and phone number
Select a 5-digit Personal Identification Number (PIN) to use when talking to the IRS.
Part 4: May we speak with your third-party designee?
No.
Part 5: Sign here. You MUST complete both pages of Form 941 and SIGN it.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Sign your
name here
Print your
name here
Date
/ /
Best daytime phone
()–
Paid preparer’s use only
Print your
title here
()–
Preparer’s name
City
State
Form 941-V,
Payment Voucher
Purpose of Form
Complete Form 941-V, Payment Voucher, if you are
making a payment with Form 941, Employer’s
QUARTERLY Federal Tax Return. We will use the
completed voucher to credit your payment more
promptly and accurately, and to improve our service to
you.
Otherwise, you must deposit your payment at an
authorized financial institution or by using the
Electronic Federal Tax Payment System (EFTPS). See
section 11 of Pub. 15 (Circular E) for deposit
instructions. Do not use Form 941-V to make federal
tax deposits.
Specific Instructions
Box 1—Employer identification number (EIN). If you
do not have an EIN, apply for one on Form SS-4,
Application for Employer Identification Number, and
write “Applied For” and the date you applied in this
entry space.
●Enclose your check or money order made payable to
the “United States Treasury.” Be sure to enter your
EIN, “Form 941,” and the tax period on your check or
money order. Do not send cash. Do not staple Form
941-V or your payment to Form 941 (or to each other).
●Detach Form 941-V and send it with your payment
and Form 941 to the address in the Instructions for
Form 941.
To avoid a penalty, make your payment with Form 941
only if:
Making Payments With Form 941
● Your net taxes for the quarter (line 10 on Form 941)
are less than $2,500 and you are paying in full with a
timely filed return or
● You are a monthly schedule depositor making a
payment in accordance with the Accuracy of Deposits
Rule. See section 11 of Pub. 15 (Circular E),
Employer’s Tax Guide, for details. In this case, the
amount of your payment may be $2,500 or more.
Caution. Use Form 941-V when making any payment
with Form 941. However, if you pay an amount with
Form 941 that should have been deposited, you may
be subject to a penalty. See Deposit Penalties in
section 11 of Pub. 15 (Circular E).
If you have your return prepared by a third party and
make a payment with that return, please provide this
payment voucher to the return preparer.
Box 3—Tax period. Darken the capsule identifying the
quarter for which the payment is made. Darken only
one capsule.
Box 4—Name and address. Enter your name and
address as shown on Form 941.
Box 2—Amount paid. Enter the amount paid with
Form 941.
3
Tax period
1st
Quarter
2nd
Quarter
3rd
Quarter
4th
Quarter
Enter the amount of your payment. ©
2
Detach Here and Mail With Your Payment and Form 941.
Ä
Ä
OMB No. 1545-0029
Form
941-V
Department of the Treasury
Internal Revenue Service
Payment Voucher
Enter your employer identification
number (EIN).
4
Enter your business name (individual name if sole proprietor).
©Do not staple this voucher or your payment to Form 941.
Enter your address.
Enter your city, state, and ZIP code.
1
Dollars
Cents
Note. You must also complete the entity information
above Part 1 on Form 941.
✁
✃
20
09
You are not required to provide the information
requested on a form that is subject to the Paperwork
Reduction Act unless the form displays a valid OMB
control number. Books and records relating to a form
or instructions must be retained as long as their
contents may become material in the administration of
any Internal Revenue law.
Privacy Act and Paperwork Reduction Act Notice.
We ask for the information on Form 941 to carry out
the Internal Revenue laws of the United States. We
need it to figure and collect the right amount of tax.
Subtitle C, Employment Taxes, of the Internal Revenue
Code imposes employment taxes on wages, including
income tax withholding. This form is used to determine
the amount of the taxes that you owe. Section 6011
requires you to provide the requested information if the
tax is applicable to you. Section 6109 requires filers
and paid preparers to provide their identifying
numbers. If you fail to provide this information in a
timely manner, you may be subject to penalties and
interest.
Recordkeeping
The time needed to complete and file Form 941 will
vary depending on individual circumstances. The
estimated average time is:
Learning about the law or the form
Preparing the form
Copying, assembling, and sending
the form to the IRS 16 min.
12 hr., 39 min.
40 min.
1 hr., 49 min.
If you have comments concerning the accuracy of
these time estimates or suggestions for making Form
941 simpler, we would be happy to hear from you. You
can write to: Internal Revenue Service, Tax Products
Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111
Constitution Ave. NW, IR-6526, Washington, DC
20224. Do not send Form 941 to this address. Instead,
see Where Should You File? on page 4 of the
Instructions for Form 941.
Form 941 (Rev. 4-2009)
Generally, tax returns and return information are
confidential, as required by section 6103. However,
section 6103 allows or requires the IRS to disclose or
give the information shown on your tax return to others
as described in the Code. For example, we may
disclose your tax information to the Department of
Justice for civil and criminal litigation, and to cities,
states, the District of Columbia, and U.S.
commonwealths and possessions for use in
administering their tax laws. We may also disclose this
information to other countries under a tax treaty, to
federal and state agencies to enforce federal nontax
criminal laws, or to federal law enforcement and
intelligence agencies to combat terrorism.
