Form 941 - Employer'S Quarterly Federal Tax Return - 2012

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941 for 2012:
950112
Employer’s QUARTERLY Federal Tax Return
Form
OMB No. 1545-0029
Department of the Treasury — Internal Revenue Service
(Rev. January 2012)
Employer identification number
—
Report for this Quarter of 2012
(EIN)
(Check one.)
Name (not your trade name)
1: January, February, March
2: April, May, June
Trade name (if any)
3: July, August, September
Address
4: October, November, December
Number
Street
Suite or room number
Prior-year forms are available at
City
State
ZIP code
Read the separate instructions before you complete Form 941. Type or print within the boxes.
Answer these questions for this quarter.
Part 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)
1
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2
Wages, tips, and other compensation
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2
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3
Income tax withheld from wages, tips, and other compensation
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3
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 .
× .104 =
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5b
Taxable social security tips .
.
× .104 =
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5c
Taxable Medicare wages & tips.
× .029 =
.
Add Column 2 line 5a, Column 2 line 5b, and Column 2 line 5c
5d
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5d
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5e
Section 3121(q) Notice and Demand—Tax due on unreported tips (see instructions)
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5e
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6
Total taxes before adjustments (add lines 3, 5d, and 5e) .
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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 .
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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
Total deposits for this quarter, including overpayment applied from a prior quarter and
11
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11
overpayment applied from Form 941-X or Form 944-X .
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12a
COBRA premium assistance payments (see instructions)
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12a
12b
Number of individuals provided COBRA premium assistance .
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13
Add lines 11 and 12a .
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13
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14
Balance due. If line 10 is more than line 13, enter the difference and see instructions
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14
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15
Overpayment. If line 13 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.
941
For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.
Form
(Rev. 1-2012)
Cat. No. 17001Z

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