Form 941 - Employer'S Quarterly Federal Tax Return, Form 941-V - Payment Voucher - 2016
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4941 for 2016:
Employer’s QUARTERLY Federal Tax Return
950114
Form
OMB No. 1545-0029
Department of the Treasury — Internal Revenue Service
(Rev. January 2016)
Report for this Quarter of 2016
—
Employer identification number (EIN)
(Check one.)
1: January, February, March
Name (not your trade name)
2: April, May, June
Trade name (if any)
3: July, August, September
Address
4: October, November, December
Number
Street
Suite or room number
Instructions and prior year forms are
available at
City
State
ZIP code
Foreign country name
Foreign province/county
Foreign postal code
Read the separate instructions before you complete Form 941. Type or print within the boxes.
Answer these questions for this quarter.
Part 1:
1
Number of employees who received wages, tips, or other compensation for the pay period
1
including: Mar. 12 (Quarter 1), June 12 (Quarter 2), Sept. 12 (Quarter 3), or Dec. 12 (Quarter 4)
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2
Wages, tips, and other compensation
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2
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3
Federal income tax withheld from wages, tips, and other compensation .
3
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4
If no wages, tips, and other compensation are subject to social security or Medicare tax
Check and go to line 6.
Column 1
Column 2
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5a
Taxable social security wages .
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× .124 =
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5b
Taxable social security tips .
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× .124 =
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5c
Taxable Medicare wages & tips.
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× .029 =
Taxable wages & tips subject to
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5d
× .009 =
Additional Medicare Tax withholding
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5e
Add Column 2 from lines 5a, 5b, 5c, and 5d
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5e
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5f
Section 3121(q) Notice and Demand—Tax due on unreported tips (see instructions)
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5f
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6
Total taxes before adjustments. Add lines 3, 5e, and 5f .
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6
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7
Current quarter’s adjustment for fractions of cents .
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7
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8
Current quarter’s adjustment for sick pay .
8
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9
Current quarter’s adjustments for tips and group-term life insurance
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9
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10
Total taxes after adjustments. Combine lines 6 through 9
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10
11
Total deposits for this quarter, including overpayment applied from a prior quarter and
overpayments applied from Form 941-X, 941-X (PR), 944-X, or 944-X (SP) filed in the
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current quarter .
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11
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Balance due. If line 10 is more than line 11, enter the difference and see instructions
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12
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13
Overpayment. If line 11 is more than line 10, enter the difference
Check one:
Apply to next return.
Send a refund.
Next
You MUST complete both pages of Form 941 and SIGN it.
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▶
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941
For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.
Form
(Rev. 1-2016)
Cat. No. 17001Z
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