Form 941-SS Employer's QUARTERLY Federal Tax Return: American Samoa,

941-SS for 2010:

Employer’s QUARTERLY Federal Tax Return

Form
American Samoa, Guam, the Commonwealth of the Northern
(Rev. January 2010)
Mariana Islands, and the U.S. Virgin Islands
Department of the Treasury — Internal Revenue Service
(EIN)
Employer identification number

—

OMB No. 1545-0029

Report for this Quarter of 2010
(Check one.)

Name (not your trade name)

1: January, February, March
Trade name (if any)

2: April, May, June

Address

3: July, August, September
Number

Street

Suite or room number

4: October, November, December
City

State

ZIP code

Read the separate instructions before you complete Form 941-SS. 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), Dec. 12 (Quarter 4)

1

2
3
4
5

If no wages, tips, and other compensation are subject to social security or Medicare tax
Taxable social security and Medicare wages and tips:
Column 1
Column 2
3 .124 =
5a Taxable social security wages
3 .124 =
5b Taxable social security tips
3 .029 =
5c Taxable Medicare wages & tips

.
.
.

Check and go to line 7.

.
.
.

5d Total social security and Medicare taxes (Column 2, lines 5a + 5b + 5c = line 5d)

.

5d

6
7

CURRENT QUARTER’S ADJUSTMENTS, for example, a fractions of cents adjustment.
See the instructions.
7a Current quarter’s fractions of cents
7b Current quarter’s sick pay
7c Current quarter’s adjustments for tips and group-term life insurance

.
.
.

7d TOTAL ADJUSTMENTS. Combine all amounts on lines 7a through 7c
8

.
.

7d

Total taxes after adjustments. Combine lines 5d and 7d

8

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

12a COBRA premium assistance payments (see instructions)
12b Number of individuals provided COBRA premium
assistance reported on line 12a

.
.

13

Add lines 11 and 12a

13

14

Balance due. If line 8 is more than line 13, write the difference here
For information on how to pay, see the instructions.
Overpayment. If line 13 is more than line 8, write the difference here

14

15

©

.

.
.
Check one

Apply to next return.
Send a refund.
Next ©

You MUST complete both pages of Form 941-SS and SIGN it.

For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.

Cat. No. 17016Y

Form

941-SS

(Rev. 1-2010)

Name (not your trade name)

Employer identification number (EIN)

Part 2: Tell us about your deposit schedule and tax liability for this quarter.
If you are unsure about whether you are a monthly schedule depositor or a semiweekly schedule depositor, see Pub. 80
(Circular SS), section 8.

16
17

Check one:

Line 8 on this return is less than $2,500 or line 8 on the return for the preceding quarter was less than
$2,500, and you did not incur a $100,000 next-day deposit obligation during the current quarter. Go to Part 3.
You were a monthly schedule depositor for the entire quarter. Enter your tax liability
for each month. Then go to Part 3.
Tax liability:

Month 1
Month 2
Month 3

.
.
.
.

Total liability for quarter
Total must equal line 8.
You were a semiweekly schedule depositor for any part of this quarter. Complete Schedule B (Form 941):
Report of Tax Liability for Semiweekly Schedule Depositors, and attach it to Form 941-SS.

Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank.
18

If your business has closed or you stopped paying wages

Check here, and

19

/
/
enter the final date you paid wages
.
If you are a seasonal employer and you do not have to file a return for every quarter of the year

Check here.

Part 4: May we speak with your third-party designee?
Do you want to allow an employee, a paid tax preparer, or another person to discuss this return with the IRS? See the instructions
for details.
(

Yes. Designee’s name and phone number

)

–

Select a 5-digit Personal Identification Number (PIN) to use when talking to IRS.
No.

Part 5: Sign here. You MUST complete both pages of Form 941-SS and SIGN it.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Print your
name here

Sign your
name here

Date

Print your
title here
/

Best daytime phone (

/

Paid preparer’s use only

Preparer’s
SSN/PTIN

Preparer’s signature

Date

Firm’s name (or yours
if self-employed)

EIN

Address

Phone

Page

State

2

–

Check if you are self-employed

Preparer’s name

City

)

/

(

/

)

–

ZIP code
Form

941-SS

(Rev. 1-2010)

Form 941-V(SS),
Payment Voucher

Complete Form 941-V(SS), Payment Voucher, if you
are making a payment with Form 941-SS, Employer’s
QUARTERLY Federal Tax Return. We will use the
completed voucher to credit your payment more
promptly and accurately, and to improve our service to
you.
If you have your return prepared by a third party and
make a payment with that return, please provide this
payment voucher to the return preparer.

Making Payments With Form 941-SS
To avoid a penalty, make your payment with Form
941-SS only if:
● Your net taxes for either the current quarter or the
preceding quarter (line 8 on Form 941-SS) are less than
$2,500, you did not incur a $100,000 next-day deposit
obligation during the current quarter, and you are
paying in full with a timely filed return or
● You are a monthly schedule depositor making a
payment in accordance with the Accuracy of Deposits
Rule. See section 8 of Pub. 80 (Circular SS), Federal
Tax Guide for Employers in the U.S. Virgin Islands,
Guam, American Samoa, and the Commonwealth of the
Northern Mariana Islands, for details. In this case, the
amount of your payment may be $2,500 or more.
Otherwise, you must deposit your payment at an
authorized financial institution or by using the Electronic
Federal Tax Payment System (EFTPS). See section 8 of
Circular SS for deposit instructions. Do not use Form
941-V(SS) to make federal tax deposits.

Ä

Department of the Treasury
Internal Revenue Service

Specific Instructions
Box 1—Employer identification number (EIN). If you
do not have an EIN, apply for one on Form SS-4,
Application for Employer Identification Number, and
write “Applied For” and the date you applied in this
entry space.
Box 2—Amount paid. Enter the amount paid with
Form 941-SS.
Box 3—Tax period. Darken the circle identifying the
quarter for which the payment is made. Darken only
one circle.
Box 4—Name and address. Enter your name and
address as shown on Form 941-SS.
● Enclose your check or money order payable to the
“United States Treasury.” Be sure to enter your EIN,
“Form 941-SS,” and the tax period on your check or
money order. Do not send cash. Do not staple Form
941-V(SS) or your payment to Form 941-SS (or to each
other).
● Detach Form 941-V(SS) and send it with your
payment and Form 941-SS to the address in the
Instructions for Form 941-SS.
Note. You must also complete the entity information
above Part 1 on Form 941-SS.

Detach Here and Mail With Your Payment and Form 941-SS. Ä

OMB No. 1545-0029

Payment Voucher

Form

✁
941-V(SS)

Caution. Use Form 941-V(SS) when making any
payment with Form 941-SS. However, if you pay an
amount with Form 941-SS that should have been
deposited, you may be subject to a penalty. See
Deposit Penalties in section 8 of Pub. 80 (Circular SS).

✃

Purpose of Form

©

2

Dollars

3

4 Enter your business name (individual name if sole proprietor).

Enter the amount of your payment.

Tax period

2010

Do not staple this voucher or your payment to Form 941-SS.

1 Enter your employer identification
number (EIN).

1st
Quarter

3rd
Quarter

Enter your address.

2nd
Quarter

4th
Quarter

Enter your city, state, and ZIP code.

©

Cents

Form 941-SS (Rev. 1-2010)

Privacy Act and Paperwork Reduction Act Notice.
We ask for the information on Form 941-SS to carry
out the Internal Revenue laws of the United States. We
need it to figure and collect the right amount of tax.
Subtitle C, Employment Taxes, of the Internal Revenue
Code imposes employment taxes on wages. This form
is used to determine the amount of the taxes that you
owe. Section 6011 requires you to provide the
requested information if the tax is applicable to you.
Section 6109 requires filers and paid preparers to
provide their identifying numbers. If you fail to provide
this information in a timely manner, you may be
subject to penalties and interest.
You are not required to provide the information
requested on a form that is subject to the Paperwork
Reduction Act unless the form displays a valid OMB
control number. Books and records relating to a form
or instructions must be retained as long as their
contents may become material in the administration of
any Internal Revenue law.
Generally, tax returns and return information are
confidential, as required by section 6103. However,
section 6103 allows or requires the IRS to disclose or
give the information shown on your tax return to others
as described in the Code. For example, we may
disclose your tax information to the Department of

Justice for civil and criminal litigation, and to cities,
states, the District of Columbia, and U.S.
commonwealths and possessions for use in
administering their tax laws. We may also disclose this
information to other countries under a tax treaty, to
federal and state agencies to enforce federal nontax
criminal laws, or to federal law enforcement and
intelligence agencies to combat terrorism.
The time needed to complete and file Form 941-SS
will vary depending on individual circumstances. The
estimated average time is:
Recordkeeping
Learning about the law or the form
Preparing the form
Copying, assembling, and sending
the form to the IRS

8 hr., 7 min.
18 min.
24 min.
0 min.

If you have comments concerning the accuracy of
these time estimates or suggestions for making Form
941-SS simpler, we would be happy to hear from you.
You can write to: Internal Revenue Service, Tax
Products Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW,
IR-6526, Washington, DC 20224. Do not send Form
941-SS to this address. Instead, see Where Should
You File? on page 2 of the Instructions for Form
941-SS.