Form 941-X Draft - Adjusted Employer'S Quarterly Federal Tax Return Or Claim For Refund - 2012 Page 3
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1
2
3
4
5Name (not your trade name)
Employer identification number (EIN)
Correcting quarter
(1, 2, 3, 4)
Correcting calendar year (YYYY)
Part 3:
Enter the corrections for this quarter. If any line does not apply, leave it blank.
Column 2
Column 3
Column 4
Column 1
Total corrected
Amount originally
Difference
DRAFT AS OF
amount (for ALL
reported or as
(If this amount is a
Tax correction
employees)
previously corrected
negative number,
=
—
(for ALL employees)
use a minus sign.)
6. Wages, tips, and other
Use the amount in Column 1 when
=
you prepare your Forms W-2 or
compensation (Form 941, line 2)
—
.
.
.
Forms W-2c.
7. Income tax withheld from
wages, tips, and other
=
Copy Column
—
.
.
.
.
compensation (Form 941, line 3)
April 30, 2012
3 here
▶
8. Taxable social security wages
(Form 941 or Form 941-SS, line
=
—
.
.
.
.
5a, Column 1)
× .124* =
*If you are correcting a 2011 or 2012 return, use .104. If you are correcting your employer share only, use .062. See instructions.
9. Taxable social security tips
(Form 941 or Form 941-SS, line
=
—
.
.
.
.
5b, Column 1)
× .124* =
*If you are correcting a 2011 or 2012 return, use .104. If you are correcting your employer share only, use .062. See instructions.
10. Taxable Medicare wages and
tips (Form 941 or Form 941-SS,
DO NOT FILE
=
—
.
.
.
.
line 5c, Column 1)
× .029* =
*If you are correcting your employer share only, use .0145. See instructions.
11. Section 3121(q) Notice and
Demand—Tax due on unreported
=
—
Copy Column
.
.
.
.
tips (Form 941 or Form 941-SS, line
3 here
▶
5e)
12a. Number of qualified employees
first paid exempt wages/tips
*Complete lines
=
—
this quarter (Form 941 or Form
12a, 12b, and 12c
941-SS, line 6a)*
only for corrections
to quarters ending
12b. Number of qualified employees
paid exempt wages/tips this
after March 31,
=
—
quarter (Form 941 or Form 941-
2010, and before
SS, line 6b)*
January 1, 2011.
12c. Exempt wages/tips paid to
qualified employees this quarter
=
—
.
.
.
.
(Form 941 or Form 941-SS, line 6c)*
× .062 =
13. Tax adjustments (Form 941 or Form
941-SS, lines 7–9 (lines 7a–7c for
=
—
Copy Column
.
.
.
.
quarters ending before January 1, 2011))
3 here
▶
14. Special addition to wages for
=
—
See
federal income tax
.
.
.
.
instructions
15. Special addition to wages for
=
—
See
social security taxes
.
.
.
.
instructions
16. Special addition to wages for
=
—
See
Medicare taxes
.
.
.
.
instructions
.
17. Combine the amounts on lines 7–16 of Column 4
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
18. Advance earned income credit
(EIC) payments made to employees
=
—
See
.
.
.
.
(Form 941, line 9; only for quarters
instructions
ending before January 1, 2011)
19a. COBRA premium assistance
payments (Form 941 or Form
=
—
See
.
.
.
.
941-SS, line 12a)
instructions
19b. Number of individuals provided
COBRA premium assistance
(Form 941 or Form 941-SS, line
=
—
*Complete lines
12b)
19c and 19d only
19c. Number of qualified employees paid
for corrections to
exempt wages/tips March 19–31, 2010
=
the second quarter
—
(Form 941 or Form 941-SS, line 12c)*
of 2010.
19d. Exempt wages/tips paid to
qualified employees March 19–
=
—
.
.
.
.
31, 2010 (Form 941 or Form
× .062 =
941-SS, line 12d)*
.
20. Total. Combine the amounts on lines 17–19d of Column 4. Continue on next page
.
.
.
.
.
.
.
.
.
.
.
Next
▶
■
2
941-X
Page
Form
(Rev. 4-2012)
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