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.
Part 2: Tell us about your deposit schedule and tax liability for this quarter.
Part 3: Tell us about your business. If a question does NOT apply to your business, leave it
blank.
Part 4: May we speak with your third-party designee?
Part 5: Sign here. You MUST complete both pages of Form 941 and SIGN it.
17 If your business has closed or you stopped paying wages . . . . . . . . . . . . . . .
enter the final date you paid wages
18 If you are a seasonal employer and you don’t have to file a return for every quarter of the year . .
Name (not your trade name)
Bridget Duval
Employer identification number (EIN)
33-4158215
If you are unsure about whether you are a monthly schedule depositor or a semiweekly schedule depositor, see section 11
of Pub. 15.
Line 12 on this return is less than $2,500 or line 12 on the return for the prior quarter was less than $2,500, and you didn’t
incur a $100,000 next-day deposit obligation during the current quarter. If line 12 for the prior quarter was less than $2,500 but
line 12 on this return is $100,000 or more, you must provide a record of your federal tax liability. If you are a monthly schedule
depositor, complete the deposit schedule below; if you are a semiweekly schedule depositor, attach Schedule B (Form 941). Go to
Part 3.
You were a monthly schedule depositor for the entire quarter. Enter your tax liability for each month and total
liability for the quarter, then go to Part 3.
Total liability for quarter
Total must equal line 12.
Report of Tax Liability for Semiweekly Schedule Depositors, and attach it to Form 941.
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.