Calendar Year (YYYY)
Name
Employer identification number (EIN)
Part 3: Enter the corrections for this year. If any line does not apply, leave it blank.
Column 1
Column 2
Column 3
Column 4
Total corrected
Amount originally
Difference
Tax correction
amount (for ALL
reported or as
(If this amount is a
=
employees)
previously corrected
negative number,
—
(for ALL employees)
use a minus sign.)
6.
Tier I Employer Tax–
.062
=
.
—
=
Compensation
.
.
.
(from line 1 of Form CT-1)
7.
Tier I Employer Medicare Tax–
.0145
=
=
—
.
.
Compensation
.
.
(from line 2 of Form CT-1)
8.
Tier II Employer Tax–
See
=
Compensation
instructions
.
.
.
.
—
(from line 3 of Form CT-1)
9.
Tier I Employee Tax–
=
.062
=
.
.
.
.
Compensation
—
(from line 4 of Form CT-1)
10.
Tier I Employee Medicare Tax–
.0145
=
—
.
.
=
.
.
Compensation
(from line 5 of Form CT-1)
11.
Tier II Employee Tax–
See
=
.
instructions
.
Compensation
.
.
—
(from line 6 of Form CT-1)
Tier I Employer Tax–Sick Pay
12.
=
.062
=
.
.
.
(from line 7 of Form CT-1)
.
—
13.
Tier I Employer Medicare Tax–
=
.0145
=
.
.
.
Sick Pay
.
—
(from line 8 of Form CT-1)
14.
Tier I Employee Tax–Sick Pay
=
.062
=
.
(from line 9 of Form CT-1)
.
.
.
—
15.
Tier I Employee Medicare Tax–
=
.0145
=
.
Sick Pay
.
—
.
.
(from line 10 of Form CT-1)
16.
Tax Adjustments
See
=
.
.
.
instructions
(from line 12 of Form CT-1)
.
—
.
17. Total. Combine the amounts in lines 6 through 16 of Column 4
If line 17 is less than 0:
If you checked line 1, this is the amount you want applied as a credit to your Form CT-1 for the tax period in which you are
filing this form.
If you checked line 2, this is the amount you want refunded or abated.
If line 17 is more than 0, this is the amount you owe. Pay this amount when you file this return. For information on how to pay,
see Amount you owe in the instructions for line 17.
Next
2
CT-1 X
Page
Form
(1-2009)