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Form 941-X Adjusted Employer’s QUARTERLY Federal Tax Return or Claim for Refund

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This form is provided free of charge. Read the instructions before completing this form. Use this form to correct errors you made on Form 941. Use a separate Form 941-X for each quarter that needs correction. Don’t attach this form to Form 941 unless you’re reclassifying workers; see the instructions for line 42. This form must be paper filed . If a line on Form 941-X doesn't apply to you, leave it blank. If you're correcting a quarter that began before April 1, 2020, you must leave blank lines 9, 10, 17, 18a, 24, 25, 26a, 28, 29, 30, 31a, 32, 33a, and 34. If you're correcting a quarter that began before July 1, 2020, you must leave blank line 33b. If you're correcting a quarter that began before April 1, 2021, you must leave blank lines 18b, 18c, 18d, 26b, 26c, 35, 36, 37, 38, 39, and 40. If you're correcting a quarter that began before July 1, 2021, you must leave blank line 31b. If you're correcting a quarter that began after December 31, 2021, you must leave blank line 18a, 26a, 30, 31a and 31b.

To correct any credits related to the new COVID-19 lesgislation reported on your original Form 941 for the quarter, we recommend you refigure the amount of these credits by preparing a corrected Form 941 and using the amounts of the revised credits on your Form 941-X.

Type of return you are correcting:*
941
941-SS
Calendar year you are correcting:*
Enter the date you discovered errors:*
Employer identification number (EIN):*
Employer name:*
Trade name:
If you have a foreign address, click here:
Address:*
City, State and Zip code:*
Foreign province, postal code and country:
Quarter you are correcting:*
1Q: Jan, Feb, Mar
3Q: Jul, Aug, Sep
2Q: Apr, May, Jun
4Q: Oct, Nov, Dec
1. Adjusted employment tax return. Check this box if you underreported amounts. Also check this box if you overreported amounts and you would like to use the adjustment process to correct the errors. You must check this box if you’re correcting both underreported and overreported amounts on this form. The amount shown on line 27, if less than zero, may only be applied as a credit to your Form 941, Form 941-SS, or Form 944 for the tax period in which you’re filing this form.
2. Claim. Check this box if you overreported amounts only and you would like to use the claim process to ask for a refund or abatement of the amount shown on line 27. Don’t check this box if you’re correcting ANY underreported amounts on this form.
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.
Note: If you’re correcting underreported amounts only, go to Part 3 on page 2 and skip lines 4 and 5. If you’re correcting overreported amounts, for purposes of the certifications on lines 4 and 5, Medicare tax doesn’t include Additional Medicare Tax. Form 941-X can’t be used to correct overreported amounts of Additional Medicare Tax unless the amounts weren’t withheld from employee wages or an adjustment is being made for the current year.
 
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 overcollected federal income tax or Additional Medicare Tax for the current year and the overcollected social security tax and Medicare tax for current and prior years. For adjustments of employee social security tax and Medicare tax overcollected in prior years, I have a written statement from each affected employee stating that they haven'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 they haven'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 overcollected social security tax and Medicare tax. For claims of employee social security tax and Medicare tax overcollected in prior years, I have a written statement from each affected employee stating that they haven'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 overcollected in prior years, I also have a written statement from each affected employee stating that they haven'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 they haven'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.
 
Corrected Amount
 
Originally Reported
 
Difference
 
Tax Corrections
6. Wages, tips, and other compensation:
 
-
=
7. Federal income tax withheld from wages, tips, and other compensation:
 
-
=
===>
8. Taxable social security wages:
 
-
=
9. Qualified sick leave wages:
 
-
=
x 0.062 =
10. Qualified family leave wages:
 
-
=
x 0.062 =
11. Taxable social security tips:
 
-
=
12. Taxable Medicare wages and tips:
 
-
=
13. Taxable wages & tips subject to Additional Medicare Tax withholding:
 
-
=
x 0.009 =
14. Section 3121(q) Notice and Demand—Tax due on unreported tips:
 
-
=
===>
15. Tax adjustments:
 
-
=
===>
16. Qualified small business payroll tax credit for increasing research activities:
 
-
=
x -1.0 =
17. Nonrefundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021:
 
-
=
x -1.0 =
18a. Nonrefundable portion of employee retention credit:
 
-
=
x -1.0 =
18b. Nonrefundable portion of credit for qualified sick and family leave wages for leave taken after March 31, 2021, and before October 1, 2021:
 
-
=
x -1.0 =
18c. Nonrefundable portion of COBRA premium assistance credit:
 
-
=
x -1.0 =
18d. Number of individuals provided COBRA premium assistance:
 
-
=
19. Special addition to wages for federal income tax:
 
-
=
20. Special addition to wages for social security taxes:
 
-
=
21. Special addition to wages for Medicare taxes:
 
-
=
22. Special addition to wages for Additional Medicare Tax:
 
-
=
23. Subtotal:
24. Deferred amount of social security tax:
 
-
=
x -1.0 =
25. Refundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021:
 
-
=
x -1.0 =
26a. Refundable portion of employee retention credit:
 
-
=
x -1.0 =
26b. Refundable portion of credit for qualified sick and family leave wages for leave taken after March 31, 2021, and before October 1, 2021:
 
-
=
x -1.0 =
26c. Refundable portion of COBRA premium assistance credit:
 
-
=
x -1.0 =
27. Total:
If line 27 is less than zero:
• If you checked line 1, this is the amount you want applied as a credit to your Form 941 for the tax period in which you're filing this form. (If you're currently filing a Form 944, Employer’s ANNUAL Federal Tax Return, see the instructions.)
• If you checked line 2, this is the amount you want refunded or abated.

If line 27 is more than zero, this is the amount you owe. Pay this amount by the time you file this return. For information on how to pay, see Amount you owe in the instructions.
28. Qualified health plan expenses allocable to qualified sick leave wages for leave taken before April 1, 2021:
 
-
=
29. Qualified health plan expenses allocable to qualified family leave wages for leave taken before April 1, 2021:
 
-
=
30. Qualified wages for the employee retention credit:
 
-
=
31a. Qualified health plan expenses for the employee retention credit:
 
-
=
31b. Check here if you’re eligible for the employee retention credit in the third or fourth quarter of 2021 solely because your business is a recovery startup business.
32. Credit from Form 5884-C, line 11, for this quarter:
 
-
=
33a. Qualified wages paid March 13 through March 31, 2020, for the employee retention credit:
 
-
=
33b. Deferred amount of the employee share of social security tax included on Form 941 line 13b:
 
-
=
34. Qualified health plan expenses allocable to wages reported on Form 941, line 24:
 
-
=
Coution: Lines 35–40 apply only to quarters beginning after March 31, 2021.
35. Qualified sick leave wages for leave taken after March 31, 2021, and before October 1, 2021:
 
-
=
36. Qualified health plan expenses allocable to qualified sick leave wages for leave taken after March 31, 2021, and before October 1, 2021:
 
-
=
37. Amounts under certain collectively bargained agreements allocable to qualified sick leave wages for leave taken after March 31, 2021, and before October 1, 2021:
 
-
=
38. Qualified family leave wages for leave taken after March 31, 2021, and before October 1, 2021:
 
-
=
39. Qualified health plan expenses allocable to qualified family leave wages for leave taken after March 31, 2021, and before October 1, 2021:
 
-
=
40. Amounts under certain collectively bargained agreements allocable to qualified family leave wages for leave taken after March 31, 2021, and before October 1, 2021:
 
-
=
41. Check here if any corrections you entered on a line include both underreported and overreported amounts. Explain both your underreported and overreported amounts on line 43.
42. Check here if any corrections involve reclassified workers. Explain on line 43.
 
43. You must give us a detailed explanation of how you determined your corrections. See the instructions.
Check if you are self-employed:
Name:*
Title:*
Date:*
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