Form 941-M Employer's Monthly Federal Tax Return

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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 941-M, PAGE 1 of 2
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 432mm (17") 3 279mm (11") FOLDED TO 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON VERTICAL FOLD

Date

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

Action

Date

Signature

O.K. to print
Revised proofs
requested

Additions / changes.

Reviewed by ME 5/10/10
OK-to-Print As Corrected
in green. Text edits (deletions) in red.
COMP Analyst: Grid is 1/10" x 1/12". Keep entryChanges
spaces
on grid.

Deletions.

Math checks.

Reference checks.

941-M for 2010:

Form
(Rev. April 2010)

Employer’s MONTHLY Federal Tax Return
—

Name (not your trade name)

Trade name (if any)

Address

Number

© Do not file this form unless instructed to do so by the IRS.

Department of the Treasury — Internal Revenue Service

(EIN)
Employer identification number

Street

City

OMB No. 1545-0718

f
o
s
a
0
t
1
f
0
a
2
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/
D /14
4
0.
.

Report for this Month of 2010
(Check ONE month only.)

Suite or room number

State

ZIP code

Jan.

Feb.

March

April

May

June

July

Aug.

Sept.

Oct.

Nov.

Dec.

Read the separate instructions before you complete Form 941-M. Type or print within the boxes.

Part 1: Answer these questions for this month.
1

d (line 5)

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)

"x" should be lower
case for multiplication

2

Wages, tips, and other compensation

3

Income tax withheld from wages, tips, and other compensation

4

If no wages, tips, and other compensation are subject to social security or Medicare tax
Column 1
Column 2
and

5a Taxable social security wages*
5b Taxable social security tips*
5c Taxable Medicare wages & tips*

.
.

3 .124 =

3 .029 =

Delete points

6a Number of qualified employees first paid exempt wages/tips this month
6b Number of qualified employees paid exempt wages/tips this month

.

6c Exempt wages/tips paid to qualified employees this month

d (line 7d)

.
.

x .062 =

6e Total taxes before adjustments (lines 3 + 5d — line 6d = line 6e)

7b Current month’s adjustment for sick pay

Check and go to line 6e.

7c Current month’s adjustments for tips and group-term life insurance

See instructions for definitions of
“qualified employees” and
“exempt wages/tips.”

7a
7b
7c

Total taxes after adjustments. Combine lines 6e through 7c

8

9

Advance earned income credit (EIC) payments made to employees

9

10

Total taxes after adjustment for advance EIC (line 8 – line 9 = line 10)

10

11

Total deposits for this month. Enter the amount from page 2, line 16b

11

12b Number of individuals provided COBRA premium assistance

d (reported on line 12a)

12a

endash

Complete lines 12c, 12d,
and 12e only for April 2010.

12c Number of qualified employees paid exempt wages/tips March 19 -31

.

12d Exempt wages/tips paid to qualified employees March 19-31

endash

Add lines 11, 12a, and 12e

14

Balance due. If line 10 is more than line 13, enter the difference and see instructions

15

Overpayment. If line 13 is more than line 10, enter the difference

.

.
.
.

x .062 = 12e

13

©

.
.
.
.
.
.
.
.
.
.

6d

8

12a COBRA premium assistance payments (see instructions)

.

5d

6e

Delete bold from
parenthetical statement

13
14

Check one:

Apply to next return.

Send a refund.

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

For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.

endash

* Report wages/tips for this
month, including those paid to
qualified new employees, on lines
5a-5c. Your liability for exempt
wages/tips will be reduced on
line 6d (see instructions).

.
.

3 .124 =

7a Current month’s adjustment for fractions of cents

.
.

2
3

5d Add Column 2 line 5a, Column 2 line 5b, Column 2 line 5c

d (line 7)

1

Next ©
Cat. No. 17013R

Form

941-M

(Rev. 04-2010)

4
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 941-M, PAGE 2 of 2
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 432mm (17") 3 279mm (11") FOLDED TO 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON VERTICAL FOLD

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

Name (not your trade name)

Employer identification number (EIN)

f
o
s
a
0
t
1
f
0
a
2
r
/
D /14
4
0

Part 2: Tell us about your tax liability and deposits for this month.
16

Record of Federal Tax Liability and Deposits. Read the instructions for this line.
Tax Liability

Overpayment from
previous month

Amount Deposited
©

1
2
3
4
5
6
7
8
9
10

Tax Liability

Amount Deposited

Tax Liability

12

23

13

24

14

25

15

26

16

27

17

28

18

29

19

30

20

31

21

11

22

a Total tax liability for the month (must equal line 10 on page 1). Add lines 1–31 in
the Tax Liability columns

16a

b Total deposits for the month. Add lines 1–31 (including overpayment from
previous month) in the Amount Deposited columns

16b

17

Amount Deposited

Copy the amount shown on line 16b in Part 2 to line 11 in Part 1.

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
enter the final date you paid wages

19

/

/

Check here, and

.

If you are a seasonal employer and you do not have to file a return for every month 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 the IRS.
No.

Part 5: Sign here. You MUST complete both pages of Form 941-M 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
Sign your
name here
name here
Print your
title here
Date

/

/

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-M

(Rev. 04-2010)