941-X Form

Email*

Tax Year

Check the type of return you’re correcting

941
941-SS

Check the ONE quarter you’re correcting

Q1 - January, February, March
Q2 - April, May, June
Q3 - July, August, September
Q4 - October, November, December

Enter the calendar year of the quarter you’re correcting

Enter the date you discovered errors

Employer Identification Number

Name (not your trade name)

Trade Name (if any)

Country

Address (Number and Street)

Apt/Ste No.

City

State

Zip Code

Foreign Province, State, County

Foreign Postal Code

Part 1: Process Selection

Select ONLY one process

1. Adjusted employment tax return
2. Claim

Part 2: Complete the certifications:

3. I certify that I’ve filed or will file Forms W-2, Wage and Tax Statement, or Forms W-2c, Corrected Wage and Tax Statement, as required.

3. I certify that I’ve filed or will file Forms W-2, Wage and Tax Statement, or Forms W-2c, Corrected Wage and Tax Statement, as required.

Are you correcting under reported tax only?

Yes
No

4. If you checked line 1 because you’re adjusting overreported federal income tax, social security tax, Medicare tax, or Additional Medicare Tax, check all that apply. You must check at least one box. I certify that:

a. I repaid or reimbursed each affected employee for the over collected federal income tax or Additional Medicare Tax for the current year and the over collected social security tax and Medicare tax for current and prior years. For adjustments of employee social security tax and Medicare tax over collected in prior years, I have a written statement from each affected employee stating that he or she hasn’t claimed (or the claim was rejected) and won’t claim a refund or credit for the overcollection.
b. The adjustments of social security tax and Medicare tax are for the employer’s share only. I couldn’t find the affected employees or each affected employee didn’t give me a written statement that he or she hasn’t claimed (or the claim was rejected) and won’t claim a refund or credit for the overcollection.
c. The adjustment is for federal income tax, social security tax, Medicare tax, or Additional Medicare Tax that I didn’t withhold from employee wages.

5. If you checked line 2 because you’re claiming a refund or abatement of overreported federal income tax, social security tax, Medicare tax, or Additional Medicare Tax, check all that apply. You must check at least one box. I certify that:

a. I repaid or reimbursed each affected employee for the over collected social security tax and Medicare tax. For claims of employee social security tax and Medicare tax over collected in prior years, I have a written statement from each affected employee stating that he or she hasn’t claimed (or the claim was rejected) and won’t claim a refund or credit for the overcollection.
b. I have a written consent from each affected employee stating that I may file this claim for the employee’s share of social security tax and Medicare tax. For refunds of employee social security tax and Medicare tax over collected in prior years, I also have a written statement from each affected employee stating that he or she hasn’t claimed (or the claim was rejected) and won’t claim a refund or credit for the overcollection.
c. The claim for social security tax and Medicare tax is for the employer’s share only. I couldn’t find the affected employees, or each affected employee didn’t give me a written consent to file a claim for the employee’s share of social security tax and Medicare tax, or each affected employee didn’t give me a written statement that he or she hasn’t claimed (or the claim was rejected) and won’t claim a refund or credit for the overcollection.
d. The claim is for federal income tax, social security tax, Medicare tax, or Additional Medicare Tax that I didn’t withhold from employee wages