Cruz Company has gathered the information needed to complete its Form 941 for the quarter ended September 30, 2017. Using the information presented below, complete Part 1 of Form 941.

• # of employees for pay period that included September 12-14 employees
• Wages paid third quarter-$78,287.49
• Federal income tax withheld in the third quarter-$9,394.50
• Taxable social security and Medicare wages-$78,287.49
• Total tax deposits for the quarter-$21,372.48

_Form941 for 20--: ^{(Rev. January 2016)}

Employer's QUARTERLY Federal Tax Return ^{Department of the Treasury Internal Revenue Service}

_{OMB No. 1545-0029}

Employer identification number(EIN)

0

0

0

0

0

6

5

0

9

Name(not your trade name)

CARLOS CRUZ

Trade name(if any)

CRUZ COMPANY

Address

901 KEYSTONE

Number

Street

Suite or room number

SACRAMENTO

CA

95916

City

State

ZIP code

Foreign country name

Foreign province/county

Foreign postal code

Report for this Quarter of 20-- (Select one.)

Instructions and prior year forms are available atwww.irs.gov/form941.

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), orDec. 12(Quarter 4)

1

2

Wages, tips, and other compensation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2

3

Federal 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 6.

		Column 1		Column 2
5a	Taxable social security wages . . . . .	x .124 =
5b	Taxable social security tips . . . . . . . .	x .124 =
5c	Taxable Medicare wages & tips . . . . .	x .029 =
5d	Taxable wages & tips subject to Additional Medicare Tax withholding	x .009 =

5e

Add Column 2 from lines 5a, 5b, 5c, and 5d. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5e

5f

Section 3121(q) Notice and DemandTax due on unreported tips(see instructions) . . . . . . . . . . . . . . .

5f

6

Total taxes before adjustments.Add lines 3, 5e, and 5f . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

7

Current quarter's adjustment for fractions of cents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7

8

Current quarter's adjustment for sick pay. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

9

Current quarter's adjustments for tips and group-term life insurance. . . . . . . . . . . . . . . . . . . . . . . . . . .

9

10

Total taxes after adjustments.Combine lines 6 through 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

11

Total deposits for this quarter, including overpayment applied from a prior quarter and overpayments applied from Form 941-X, 941-X (PR), 944-X, or 944-X (SP) filed in the current quarter. .

11

12

Balance due.If line 10 is more than line 11, enter the difference and see instructions . . . . . . . . . . . . . . . . . . . .

12

13

Overpayment.If line 11 is more than line 10, enter the differenceCheck one: Apply to next return. Send a refund.

You MUST complete both pages of Form 941 and SIGN it.

Next

For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.

Cat. No. 17001Z

Form941(Rev. 1-2016)