Form Schedule D (Form 9 Schedule D (Form 9 Report for Discrepancies Caused by Acquisitions, Statuto

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I.R.S. SPECIFICATIONS
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SCH. D (FORM 941), PAGE 1 OF 2
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Date

Action

Date

Signature

O.K. to print
Revised proofs
requested

Schedule D (Form 941):
Report of Discrepancies Caused by Acquisitions, Statutory Mergers, or Consolidations
(Rev. March 2005)

Department of the Treasury—Internal Revenue Service

OMB No. 1545-0029

Tax Year of Discrepancies (Fill in)

Employer Identification Number (EIN)

Format: YYYY

Name (not your trade name)

Trade name (if any)

Type of Submission (Check one)
Address
Number

Street

Suite or room number

Original
City

Phone number

State

(

)

Corrected

ZIP code

–

About this schedule
Each year the Internal Revenue Service (IRS) and the Social Security Administration (SSA) compare the totals on your Forms 941,
Employer’s Quarterly Federal Tax Return, with the totals on Forms W-2, Wage and Tax Statement, to verify that:
■

the wages you reported on Forms 941 match those you reported on Forms W-2 (Copy A) so that your
employees’ social security earnings records are complete for benefit purposes; and

■

you have paid the appropriate taxes.

Generally, the totals on your Forms W-2 (Copy A) should equal the totals you reported on Forms 941. Use this schedule if discrepancies
exist between the totals you reported on those forms ONLY as a result of an acquisition, statutory merger, or consolidation. In many
cases, the information on this schedule should help the IRS resolve discrepancies without contacting you. If you are an eligible
employer who elects to use the alternate procedure set forth in Rev. Proc. 2004-53, explained in the instructions, you should file this
schedule.
Read the separate instructions before you fill out this schedule.
Part 1: Answer these background questions.
1. Are you filing this schedule —
after a statutory merger or consolidation? (See Rev. Rul. 62-60, 1962-1 C.B. 186 and Rev. Proc. 2004-53, 2004-34 I.R.B. 320.)
You are either:

an acquired corporation or
a surviving corporation.

OR
after an acquisition and you are using the alternate procedure under Rev. Proc. 2004-53, 2004-34 I.R.B. 320?
You are either:

a predecessor or
a successor.
/

2. The effective date of the statutory merger/consolidation or acquisition is
MM

/

/
DD

/

YYYY

3. The OTHER PARTY in this transaction is . . .
Other party’s EIN
Other party’s name
Trade name (if any)
Address
Number

Street

Suite or room number

City

Phone number

(

State

)

ZIP code

–

For Paperwork Reduction Act Notice, see separate instructions.

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Cat. No. 38791Y

Schedule D (Form 941) Rev. 3-2005

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I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
SCH. D (FORM 941), PAGE 2 of 2
MARGINS: TOP 13 mm (1⁄2 ") CENTER SIDES.
PAPER: WHITE, WRITING, SUB. 20
FLAT SIZE: 216 mm (81⁄2 ") x 279 mm (11")
PERFORATE: NONE

PRINTS: HEAD TO HEAD
INK: BLACK

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Tax Year of Discrepancies (Fill in)

Your EIN

Format: YYYY

Name (not your trade name)

Other party’s EIN

Part 2: Tell us about the discrepancies with your returns.
Column B

Column A
Amount you reported to IRS
for the tax year

Column C

– Amount you reported to SSA
for the tax year

Totals from Forms 941 as
corrected by any Forms 941c

–– The difference

Totals from Forms W-2 (Copy A) as
corrected by any Forms W-2c (Copy A)

4. social security wages

–

––

5. Medicare wages and tips

–

––

6. social security tips

–

––

7. federal income tax
withheld
8. advance earned income
credit (EIC) payments

–

––

–

––

If you are filing for one transaction only, STOP here. If you are filing for more than one transaction, go to Part 3.

Part 3: Fill this part out ONLY if you are filing more than one Schedule D (Form 941) for any calendar year.

9. File one Schedule D (Form 941) for each separate transaction. This is schedule

. (Example: This is schedule 1 of 3.)

Column B

Column A
Amount you reported to IRS
for the tax year for the
employees affected by the
transaction reported on this
Schedule D (Form 941)

of

– Amount you reported to SSA
for the tax year for the
employees affected by the
transaction reported on this
Schedule D (Form 941)

Totals from Forms 941 as
corrected by any Forms 941c

Column C
–– The difference

Totals from Forms W-2 (Copy A) as
corrected by any Forms W-2c (Copy A)

10. social security wages

–

––

11. Medicare wages and tips

–

––

12. social security tips

–

––

13. federal income tax
withheld
14. advance earned income
credit (EIC) payments

–

––

–

––

Page

2

Schedule D (Form 941) Rev. 3-2005