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Form
941 for 2012:
(Rev. January 2012)
Employer’s QUARTERLY Federal Tax Return
Department of the Treasury — Internal Revenue Service
950112
OMB No. 1545-0029
Employer identification number
(EIN)
—
Name
(not your trade name)
Trade name
(if any)
Address
Number Street Suite or room number
City
State
ZIP code
Report for this Quarter of 2012
(Check one.)
1:
January, February, March
2:
April, May, June
3:
July, August, September
4:
October, November, December
Prior-year forms are available at
www.irs.gov/form941.
Read the separate instructions before you complete Form 941. Type or print within the boxes.
Part 1:
Answer these questions for this quarter.
1
Number
of
employees
who
received
wages,
tips,
or
other
compensation
for
the
pay
period
including:
Mar. 12
(Quarter 1),
June 12
(Quarter 2),
Sept. 12
(Quarter 3), or
Dec. 12
(Quarter 4)
1
2
Wages, tips, and other compensation
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
2
.
3
Income tax withheld from wages, tips, and other compensation
.
.
.
.
.
.
.
.
.
.
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
5
a
Taxable social security wages
.
.
.
× .104 =
.
5
b
Taxable social security tips
.
.
.
.
× .104 =
.
5
c
Taxable Medicare wages & tips
.
.
× .029 =
.
5
d
Add
Column 2
line 5a,
Column 2
line 5b, and
Column 2
line 5c
.
.
.
.
.
.
.
.
.
.
.
5d
.
5
e
Section 3121(q) Notice and Demand—Tax due on unreported tips
(see instructions)
.
.
.
.
5e
.
6
Total taxes before adjustments
(add lines 3, 5d, and 5e)
.
.
.
.
.
.
.
.
.
.
.
.
.
6
.
7
Current quarter’s adjustment for fractions of cents
.
.
.
.
.
.
.
.
.
.
.
.
.
.
7
.
8
Current quarter’s adjustment for sick pay
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
8
.
9
Current quarter’s adjustments for tips and group-term life insurance
.
.
.
.
.
.
.
.
.
9
.
10
Total taxes after adjustments.
Combine lines 6 through 9
.
.
.
.
.
.
.
.
.
.
.
.
.
10
.
11
Total
deposits
for
this
quarter,
including
overpayment
applied
from
a
prior
quarter
and
overpayment applied from Form 941-X or Form 944-X
.
.
.
.
.
.
.
.
.
.
.
.
.
11
.
12
a
COBRA premium assistance payments
(see instructions)
.
.
.
.
.
.
.
.
.
.
.
.
.
12a
.
12
b
Number of individuals provided COBRA premium assistance
.
.
.
13
Add lines 11 and 12a
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
13
.
14
Balance due.
If line 10 is more than line 13, enter the difference and see instructions
.
.
.
.
.
14
.
15
Overpayment.
If line 13 is more than line 10, enter the difference
.
Check one:
Apply to next return.
Send a refund.
▶
You MUST complete both pages of Form 941 and SIGN it.
Next
■
▶
For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.
Cat. No. 17001Z
Form
941
(Rev. 1-2012)