Form 941-V (SS) 941-V (SS) Payment Voucher

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.



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. 

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