Form 941-X, Adjusted Employers QUARTERLY Federal Tax Return or Claim for Refund

After thoroughly reading the instructions, applicant can proceed to the completion of this form. This form allows for the correction of erroneous details on a previously-filed Form 941 (2016) or Form 941-SS (2016). Form 941 is the Employer’s Quarterly Federal Tax Return form. On the other hand, Form 941-SS is the Employer’s Quarterly Federal Tax Return Applicable in American Samoa, Guam, the Commonwealth of the Northern Marian Islands, and the US Virgin Islands.Download

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Form   	941-X:	(Rev. April 2015)	Adjusted Employer's QUARTERLY Federal Tax Return or Claim for Refund	Department of the Treasury — Internal Revenue ServiceOMB No. 1545-0029	
Employer identification number 
(EIN)	—	
Name (not your trade name)
Trade name (if any)
Address	
Number                                 Street                           \
                                                            Suite or roo\
m number
City	State	ZIP code	
Foreign country name	Foreign province/county	Foreign postal code	
Read the separate  instructions  before completing  this form.  Use this form  to correct 
errors  you made  on Form  941 or 941-SS.  Use a separate  Form 941-X  for each  quarter 
that  needs  correction.  Type or print  within  the boxes.  You MUST  complete  all three 
pages. Do not attach this form to Form 941 or 941-SS.	
Return You Are Correcting ...
Check the type of return you are correcting:	
941
941-SS	
Check the ONE quarter you are correcting:	
1:  January, February, March
2:  April, May, June
3:  July, August, September
4:  October, November, December	
Enter the calendar year of the 
quarter you are correcting:	
(YYYY)	
Enter the date you discovered errors:	
/	/	
(MM / DD / YYYY)	
Part 1: 	Select ONLY one process. See page 4 for additional guidance.	
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 are correc\
ting both  
underreported and overreported amounts on this form. The amount shown on\
 line 20, if  
less than zero, may only be applied as a credit to your Form 941, Form 9\
41-SS, or   
Form 944 for the tax period in which you are filing this form.
2. Claim. Check this box if you overreported amounts only and you would like to us\
e the  
claim process to ask for a refund or abatement of the amount shown on li\
ne 20. Do not  
check this box if you are correcting ANY underreported amounts on this f\
orm.	
Part 2: 	Complete the certifications.	
3. I certify  that I have  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  are correcting  underreported  amounts only, go to Part  3 on  page  2 and  skip  lines  4 and  5. If you  are correcting  overreported 
amounts,  for purposes  of the  certifications  on lines  4 and  5, Medicare  tax does  not include  Additional  Medicare Tax.  Form  941-X  cannot  be 
used  to correct  overreported  amounts of Additional  Medicare Tax unless  the amounts  were not withheld  from employee  wages or an 
adjustment is being made for the current year.
4. If you checked line 1 because you are adjusting overreported amounts, ch\
eck all that apply.  You must check at least one box. 
I certify that: 	
a. I repaid or reimbursed each affected employee for the overcollected fede\
ral income tax or Additional Medicare Tax for the current 
year and the overcollected social security tax and Medicare tax for curr\
ent and prior years. For adjustments of employee social 
security tax and Medicare tax overcollected in prior years, I have a wri\
tten statement from each affected employee stating that he 
or she has not claimed (or the claim was rejected) and will not claim \
a refund or credit for the overcollection.
b.
The adjustments of social security tax and Medicare tax are for the empl\
oyer’s share only. I could not find the affected employees 
or each affected employee did not give me a written statement that he or\
 she has not claimed (or the claim was rejected) and will 
not 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 did not withhold from 
employee wages.
5. If you checked line 2 because you are claiming a refund or abatement of \
overreported employment taxes, 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 soci\
al security tax and Medicare tax. For claims of employee 
social security tax and Medicare tax overcollected in prior years, I hav\
e a written statement from each affected employee stating 
that he or she has not claimed (or the claim was rejected) and will no\
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 Me\
dicare tax overcollected in prior years, I also have a 
written statement from each affected employee stating that he or she has\
 not claimed (or the claim was rejected) and will not 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 could not find the affected employees; or each 
affected employee did not 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 did not give me a written statement that \
he or she has not claimed (or the claim was rejected) and 
will not 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 did not withhold from 
employee wages.	
Next 	■▶
For Paperwork Reduction Act Notice, see the instructions.	
IRS.gov/form941x Cat. No. 17025JForm 	941-X	 (Rev. 4-2015)

Name (not your trade name)	Employer identification number (EIN)	Correcting quarter	(1, 2, 3, 4)	
Correcting calendar year  (YYYY)	
Part 3: 	Enter the corrections for this quarter. If any line does not apply, leav\
e it blank.	
Column 1	
Total corrected  
amount (for ALL 
employees)—	
Column 2	
Amount originally 
reported or as 
previously corrected 
(for ALL employees)	
=	
Column 3
Difference 
(If this amount is a 
negative number,  
use a minus sign.)	
Column 4
Tax correction	
6. Wages, tips and other 
compensation (Form 941, line 2) 	.	—	.	=	.	Use the amount in Column 1 when you 
prepare your Forms W-2 or Forms W-2c.	
7. 
  Federal income tax withheld 
from wages, tips, and other 
compensation (Form 941, line 3)	.	—	.	=	.	Copy Column  
3 here 	▶	.
8.  Taxable social security wages 
(Form 941 or 941-SS, line 5a, 
Column 1)	
.	—	.	=	.
×  .124* =	.	
*If you are correcting a 2011 or 2012 return, use .104. If you are corre\
cting your employer share only, use .062. See instructions.	
9. 	Taxable social security tips (Form 
941 or 941-SS, line 5b, Column 1)	.	—	.	=	.×  .124* =	.	
*If you are correcting a 2011 or 2012 return, use .104. If you are corre\
cting your employer share only, use .062. See instructions.	
10. 	Taxable Medicare wages and tips 
(Form 941 or 941-SS, line 5c, Column 1)	.	—	.	=	.×  .029* =	.	
*If you are correcting your employer share only, use .0145. See instruct\
ions.	
11. 	Taxable wages & tips subject to 
Additional Medicar e Tax withholding  
(Form 941 or 941-SS, line 5d; only for 
quarters beginning after December 31, 2012)	.	—	.	=	. ×  .009* =	.	
*Certain wages and tips reported in Column 3 should not be multiplied by\
 .009. See instructions.	
12. 	Section 3121(q) Notice and Demand —
Tax due on unreported tips  
(Form 941 or 941-SS, line 5f (line 5e for 
quarters ending before January 1, 2013))	.	—	.	=	.	Copy Column  
3 here 	▶	.
13. Tax adjustments (Form 941 or 
941-SS, lines 7–9)	
.	—	.	=	.	Copy Column  
3 here 	▶	.
14.  Special addition to wages for 
federal income tax	
.	—	.	=	.	See  
instructions	.
15.  Special addition to wages for 
social security taxes	
.	—	.	=	.	See  
instructions	.
16.  Special addition to wages for 
Medicare taxes	
.	—	.	=	.	See  
instructions	.
17.  Special addition to wages for 
Additional Medicare Tax	
.	—	.	=	.	See  
instructions	.
18. Combine the amounts on lines 7–17 of Column 4   .....................
.
19a.  COBRA premium assistance 
payments (see instructions)	
.	—	.	=	.	See  
instructions	.
19b.  Number of individuals provided 
COBRA premium assistance  
(see instructions)	
—	=	
20. Total. Combine the amounts on lines 18 and 19a of Column 4  ..................	.
If line 20 is less than zero:
• If you checked line 1, this is the amount you want applied as a cre\
dit to your Form 941 for the tax period in which you are filing this  form. (If you are currently filing a Form 944, Employer’s ANNUAL Fed\
eral Tax Return, see the instructions.)
• If you checked line 2, this is the amount you want refunded or abat\
ed.
If line 20 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.	
Next 	■▶	
Page 	2	Form 	941-X	 (Rev. 4-2015)

Name (not your trade name)	Employer identification number (EIN)	Correcting quarter	(1, 2, 3, 4)	
Correcting calendar year  (YYYY)	
Explain your corrections for this quarter.	Part 4: 	
21.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 23.
22. Check here if any corrections involve reclassified workers.  Explain on line 23.
23. You must give us a detailed explanation of how you determined your corre\
ctions.  See the instructions.	
Sign here. You must complete all three pages of this form and sign it.	Part 5: 
Under penalties of perjury, I declare that I have filed an original Form\
 941 or Form 941-SS and that I have examined this adjusted return or cla\
im, including 
accompanying schedules and statements, and to the best of my knowledge a\
nd belief, they are true, correct, and complete. Declaration of preparer\
 (other 
than taxpayer) is based on all information of which preparer has any kn\
owledge.
7	
Sign your 
name here	
Date	 /       /Print your 
name here	
Print your 
title here
Best daytime phone	
Paid Preparer Use Only	Check if you are self-employed 
..	
Preparer’s name
Preparer’s signature
Firm’s name (or yours 
if self-employed)
Address
City	State	
PTIN
Date	 /       /
EIN	
Phone
ZIP code	
Page 	3	Form 	941-X	 (Rev. 4-2015)

Form 941-X: Which process should you use?	Type of errors 
you are 
correcting
Underreported 
amounts  
ONLYUse the adjustment process to correct underreported amounts.
• Check the box on line 1.
• Pay the amount you owe from line 20 by the time you file Form 941-X\
.
Overreported 
amounts  
ONLYThe process you 
use depends on 
when you file 
Form 941-X.If you are filing Form 941-X 
MORE THAN 90 days before 
the period of limitations on 
credit or refund for Form 941  
or Form 941-SS expires... Choose either the adjustment process or the claim 
process to correct the overreported amounts.	
Choose the adjustment process if you want the 
amount shown on line 20 credited to your Form 941, 
Form 941-SS, or Form 944 for the period in which you 
file Form 941-X. Check the box on line 1.
OR
Choose the claim process if you want the amount 
shown on line 20 refunded to you or abated. Check 
the box on line 2.	
If you are filing Form 941-X 
WITHIN 90 days of the 
expiration of the period of 
limitations on credit or refund 
for Form 941 or Form 941-SS...	You must use the claim process to correct the 
overreported amounts. Check the box on line 2.	
BOTH 
underreported 
and 
overreported 
amounts The process you 
use depends on 
when you file 
Form 941-X.
If you are filing Form 941-X 
MORE THAN 90 days before 
the period of limitations on 
credit or refund for Form 941 
or Form 941-SS  expires... Choose either the adjustment process or both the 
adjustment process and the claim process when you 
correct both underreported and overreported 
amounts.	
Choose the adjustment process if combining your 
underreported amounts and overreported amounts results 
in a balance due or creates a credit that you want applied 
to Form 941, Form 941-SS, or Form 944.
• File one Form 941-X, and
• Check the box on line 1 and follow the instructions 
on line 20.
OR
Choose both the adjustment process and the 
claim process if you want the overreported amount 
refunded to you or abated.
File two separate forms.
1. For the adjustment process, file one Form 941-X  to correct the underreported amounts. Check the 
box on line 1. Pay the amount you owe from line 
20 by the time you file Form 941-X.
2. For the claim process, file a second Form 941-X  to correct the overreported amounts. Check the 
box on line 2.	
If you are filing Form 941-X 
WITHIN 90 days of the 
expiration of the period of 
limitations on credit or  
refund for Form 941 or      
Form 941-SS... You must use both the adjustment process and 
the claim process.
File two separate forms.
1. For the adjustment process, file one Form 941-X to 
correct the underreported amounts. Check the box 
on line 1. Pay the amount you owe from line 20 by 
the time you file Form 941-X.
2. For the claim process, file a second Form 941-X to  correct the overreported amounts. Check the box 
on line 2.	
Page 	4	Form 	941-X	 (Rev. 4-2015)