Form 5884-D Employee Retention Credit for Certain Tax-Exempt Organiz

Form

5884-D

Employee Retention Credit for Certain Tax-Exempt
Organizations Affected by Qualified Disasters

(April 2021)

OMB No. 1545-2298

▶ File

this form separately; do not attach it to your return.
▶ Go to www.irs.gov/Form5884D for instructions and the latest information.

Department of the Treasury
Internal Revenue Service

Employer identification number

Name (not trade name) shown on Form 941 or other employment tax return
Trade name (if any)
Number, street, and room or suite no. If a P.O. box, see instructions.
City or town, state, and ZIP code

1

If filed by a third-party payer, identify the qualified tax-exempt organization here. See instructions. Check

if not applicable.

Employer identification number

Name
Number, street, and room or suite no. If a P.O. box, see instructions.
City or town, state, and ZIP code

2a

Is the organization a qualified tax-exempt organization (an organization described in section 501(c) and
exempt from tax under section 501(a))? See instructions . . . . . . . . . . . . . . . . .
b Is the organization a federally chartered corporation, or is it a federal, state, or local college, university,
hospital, or medical care entity? See instructions . . . . . . . . . . . . . . . . . . . .
If you checked “Yes” on either line 2a or 2b, go to line 3. If you checked “No” on both lines 2a and 2b, do
not file this form; the organization cannot claim this credit.
3
Applicable 2020 qualified disaster zone(s) (see instructions):
(a)
Disaster declaration
number
DR -

-

DR -

-

DR -

-

DR -

-

(b)
Description

Yes

No

Yes

No

(c)
County, parish, or municipality name(s)

4

Check a box to indicate the employment tax return filed:
a
Form 941 b
Form 941-PR c
Form 941-SS d
Form 943 e
Form 943-PR
g
f
Form 944 (or 944(SP))
Form 944-PR h
Form 944-SS
5
Check a box or boxes to indicate the employment tax period for which the organization is claiming this credit. See instructions:
a Check year:
2019
2020
2021
(enter year)
b Check quarter (if applicable):
1st: January, February, March
2nd: April, May, June
3rd: July, August, September
4th: October, November, December

6a

Enter the organization’s total qualified wages for the 2020 qualified disaster
employee retention credit paid in all employment tax periods through the end of
the employment tax period indicated on line 5 to all eligible employees (up to
$6,000 each). See instructions . . . . . . . . . . . . . . . .
6a
b Multiply line 6a by 40% (0.40) . . . . . . . . . . . . . . . . . . .

For Paperwork Reduction Act Notice, see instructions.

Cat. No. 75321C

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.

.

.

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6b
Form 5884-D (4-2021)

Form 5884-D (4-2021)

7

Page

Enter the number of eligible employees who earned the qualified wages for the 2020 qualified disaster
employee retention credit entered on line 6a . . . . . . . . . . . . . . . . . . .

2

7

8

Enter the total amount of 2020 qualified disaster employee retention credits claimed on line 12 (minus
any amounts reported on line 13) of any Forms 5884-D filed for prior employment tax periods by or on
behalf of the organization. See instructions . . . . . . . . . . . . . . . . . . . .
Note: If line 8 is greater than line 6b, skip lines 9 through 12 and go to line 13. Otherwise, go to line 9.
9
Subtract line 8 from line 6b . . . . . . . . . . . . . . . . . . . . . . . . .
10
Enter the organization’s total taxable social security wages and tips reported on the return indicated
on line 4 for the period indicated on line 5. See instructions . . . . . . . . . . . . . .
Note: If a corrected return (for example, Form 941-X) was filed for the period indicated on line 5, enter
the amount as corrected.
11a Multiply line 10 by 6.2% (0.062) . . . . . . . . . . . . . . .
11a
b If Form 5884-C was filed for the period indicated on line 5 of this form, enter
the total amount of credits claimed on line 11 of Form 5884-C. See instructions 11b

8
9
10

c

Enter the total amount of any qualified small business payroll tax credit for
increasing research activities (Form 941, Form 943, or Form 944) filed for the
period indicated on line 5 of this form. See instructions . . . . . . . .
d Add lines 11b and 11c and subtract the total from line 11a. If the result is less
than zero, enter -0. . . . . . . . . . . . . . . . . . .
12

13

11c
11d

Credit claimed for the employment tax period indicated on line 5. Enter the smaller of line 9 or line
11d. This is the amount you are asking us to refund to you. Stop here, sign, and mail this form to the
address below. See instructions . . . . . . . . . . . . . . . . . . . . . . .
If line 8 is greater than line 6b, subtract line 6b from line 8. This is the amount you owe. Sign and mail
this form to the address below with your payment for this amount. See instructions . . . . . .

12
13

Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, correct, and complete. Declaration of preparer is based on all information of which preparer has any knowledge.
Daytime telephone number

Sign
Here
Signature of officer

Paid
Preparer
Use Only

Print/Type preparer’s name

Date

Title
Preparer’s signature

Date

Check
if
self-employed

Firm’s name

▶

Firm’s EIN

Firm’s address

▶

Phone no.

PTIN

▶

Send Form 5884-D to: Department of the Treasury, Internal Revenue Service, Ogden, UT 84201
Form 5884-D (4-2021)