Form 941-Ss Draft - Employer'S Quarterly Federal Tax Return - American Samoa, Guam, The Commonwealth Of The Northern Mariana Islands, And The U.s. Virgin Islands - 2017 Page 4

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960311
Schedule B (Form 941):
Report of Tax Liability for Semiweekly Schedule Depositors
OMB No. 1545-0029
(Rev. January 2017)
Department of the Treasury — Internal Revenue Service
Report for this Quarter...
Employer identification number
0
0
3
9
9
9
9
9
9
(Check one.)
—
(EIN)
✖
1: January, February, March
Baba Rose
DRAFT AS OF
Name (not your trade name)
2: April, May, June
2
0
1
7
3: July, August, September
Calendar year
(Also check quarter)
4: October, November, December
June 28, 2016
Use this schedule to show your TAX LIABILITY for the quarter; don't use it to show your deposits. When you file this form with Form 941 or
Form 941-SS, don't change your tax liability by adjustments reported on any Forms 941-X or 944-X. You must fill out this form and attach it to
Form 941 or Form 941-SS if you're a semiweekly schedule depositor or became one because your accumulated tax liability on any day was
$100,000 or more. Write your daily tax liability on the numbered space that corresponds to the date wages were paid. See Section 11 in
Pub. 15 for details.
Month 1
.
.
.
.
DO NOT FILE
1875
00
Tax liability for Month 1
1
9
17
25
.
.
.
.
.
2
10
18
26
.
.
.
.
3
11
19
27
.
.
.
.
4
12
20
28
.
.
.
.
5
13
21
29
.
.
.
.
1875
00
6
14
22
30
.
.
.
.
1875
00
7
15
23
31
.
.
.
1875
00
8
16
24
Month 2
.
.
.
.
1875
00
Tax liability for Month 2
1
9
17
25
.
.
.
.
1875
00
.
2
10
18
26
.
.
.
.
3
11
19
27
.
.
.
.
4
12
20
28
.
.
.
.
5
13
21
29
.
.
.
.
6
14
22
30
.
.
.
.
1875
00
7
15
23
31
.
.
.
1875
00
8
16
24
Month 3
.
.
.
.
1875
00
Tax liability for Month 3
1
9
17
25
.
.
.
.
.
2
10
18
26
.
.
.
.
3
11
19
27
.
.
.
.
4
12
20
28
.
.
.
.
5
13
21
29
.
.
.
.
2210
20
6
14
22
30
.
.
.
.
1875
00
7
15
23
31
.
.
.
8
16
24
Total liability for the quarter
Fill in your total liability for the quarter (Month 1 + Month 2 + Month 3)
.
Total must equal line 12 on Form 941 or Form 941-SS.
For Paperwork Reduction Act Notice, see separate instructions.
IRS.gov/form941
Cat. No. 11967Q
Schedule B (Form 941) (Rev. 1-2017)

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