Name Date Class
13-3 APPLICATION PROBLEM (LO4), p. 402
Reporting withholding and payroll taxes
1.
941 for 20–:
(Rev. October 20–)
Employer’s QUARTERLY Federal Tax Return
Department of the Treasury — Internal Revenue Service
(EIN)
Employer identification number
—
Name (not your trade name)
Trade name (if any)
Address
Number Street Suite or room number
City State ZIP code
Report for this Quarter of 20–
(Check one.)
1: January, February, March
2: April, May, June
3: July, August, September
4: October, November, December
Read the separate instructions before you complete Form 941. Type or print within the boxes.
Part 1: Answer these questions for this quarter.
1
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)
1
2 Wages, tips, and other compensation …………….. 2
3 Income tax withheld from wages, tips, and other compensation …….. 3
4 If no wages, tips, and other compensation are subject to social security or Medicare tax Check and go to line 6e.
2 nmuloC1 nmuloC *Report wages/tips for this quarter,
including those paid to qualified
new employees, on lines 5a–5c.
The social security tax exemption
on wages/tips will be figured on
lines 6c and 6d and will reduce the
5a Taxable social security wages* .. × .124 =
5bTaxable social security tips*. .. × .124 =
5cTaxable Medicare wages & tips* . × .029 =
7c
Current quarter’s adjustments for tips and group-term life insurance …….
7c
8 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, including prior quarter overpayments .……….. 11
12a COBRA premium assistance payments (see instructions) ………..
12a
12b Number of individuals provided COBRA premium assistance .. Complete lines 12c, 12d, and 12e
1
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Lance Clothiers
FL
5
1,851 00
0
0
0
6,434 88
6,434 88
6,434 88
29,960 00
29,960 00 3,715 04
868 84
29,960 00
0 0
33601-2500
Tampa
154 N. Morgan Street
7071 5 48 4 5
✔