Year
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Type the year for the Form 941 you are printing.
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Quarter
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Select the quarter reported on the Form 941 you are printing.
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Trade name
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Type the trade name, if any, to print on the form.
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Adjustments:
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Fractions of cents
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Type the current quarter adjustment amount for fractions of cents.
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Sick pay
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Type the current quarter adjustment amount for sick pay.
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Life insurance
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Type the current quarter adjustment amount for group-term life insurance.
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Tax Credit |
Type the current quarter adjustment amount for the qualified small business payroll tax credit for increasing research activity. |
These fields apply only to
the form for 2009 and later:
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COBRA premium payments
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Type the amount of COBRA premium assistance payments you made for eligible
individuals who paid their reduced premiums.
This amount should be 65% of the total COBRA premiums for assistance
eligible individuals without regard to the reduction. Do not include any
amounts paid to you by the individuals. For more information, see the
IRS instructions for Form 941.
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Number of individuals
|
Type the total number of individuals for whom you provided COBRA premium
assistance payments.
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These fields apply only to
the form for 2008 and earlier:
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Income tax withholding
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Type the federal withholding amount for the current year.
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Social Security
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Type the prior quarter's adjustment amount for Social Security and Medicare.
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Special income tax
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This line on the form is reserved for employers with special circumstances.
Use it only if the IRS has sent you a notice to do so.
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Special Social Security
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This line on the form is reserved for employers with special circumstances.
Use it only if the IRS has sent you a notice to do so.
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These fields apply to the
form for all years:
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Total deposits
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Type the total amount deposited for the quarter you are reporting.
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Refund overpayment
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Select this check box to select the Refund Overpayment check box on the form.
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State
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Type the state code for the state where you made your deposits. If you
made deposits in multiple states, type MU.
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Depositor option
|
Select the Monthly or Semiweekly check box to check the appropriate
box on the form.
To print Schedule B, select Semiweekly.
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Liability adjustment
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Enter the amount of the liability adjustment to print on Schedule B
of Form 941 for a prior quarter's reporting error.
Select the check box for the month in the quarter in which you are making
the liability adjustment. For example, if you are reporting Quarter 1,
select Month 2 if the error was found in February.
Type the day of the month to use for this liability adjustment. For
example, enter 13 if the error was found on the 13th of the month.
The month and day ensure that the liability adjustment appears on the
correct date line on Schedule B. If payroll was paid on the same day and
month entered for the liability adjustment, the liability adjustment amount
and the payroll amount are added together.
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No future returns
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Select this check box if your company is going out of business and will
file no future returns.
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Final date
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Enter the final date on which you paid wages that you are reporting
on this form.
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Business Closed Information: These fields apply if e-filing or printing with Box 18 checked
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Contact Name |
The name of the contact |
Address |
The first line of the address |
Address 2 |
The second line of the address
Example: Suite number
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City |
The name of the city |
State |
The name of the state |
Zip |
The zip code |
Seasonal employer
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Select this check box to select the Seasonal Employer check box on the form.
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Allow third-party designee contact
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To allow an individual, corporation, firm, organization,
or partnership to discuss your Form 941 with the IRS, select this check
box, which selects the Yes check box in the Third-Party Designee section of the
form.
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Designee's name
|
Type the name of the third-party designee.
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Personal identification number
|
Type five numbers that the third-party designee chooses as a personal
identification number.
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Phone
|
Type the third-party designee's phone number.
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Signer's name and title
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Type the name and job title of the person who signs this form.
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Date signed
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Type the date of the signature.
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Phone
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Type the phone number for the person who signs the form.
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