During the third calendar quarter of 20--, Bayview Inn, owned by Diane R. Peters, employed the persons listed below. Also given are the employees' salaries or wages and the amount of tips reported to the owner. The tips were reported by the 10th of each month. The federal income tax and FICA tax to be withheld from the tips were estimated by the owner and withheld equally over the 13 weekly pay periods. The employer's portion of FICA tax on the tips was estimated as the same amount. Salary or Quarter's Quarter's Quarter's Quarter's Quarter's Employee Wage Wages Tips OASDI HI FIT Grant Frazier $39,520/year $9,880.00 $612.56 $143.26 $840.00 Joseph LaVange 22,880/year 5,720.00 354.64 82.94 548.00 Susanne Ayers 235/week 3,055.00 $2,235.20 327.99 76.71 511.00 Howard Cohen 210/week 2,730.00 2,566.30 328.37 76.80 608.00 Lee Soong 260/week 3,380.00 2,698.20 376.85 88.13 654.00 Mary Yee 260/week 3,380.00 2,715.30 377.91 88.38 669.00 Helen Woods 315/week 4,095.00 253.89 59.38 432.00 Koo Shin 335/week 4,355.00 270.01 63.15 531.00 Aaron Abalis 410/week 5,330.00 330.46 77.29 687.00 David Harad 155/week 2,015.00 124.93 29.22 240.00 $43,940.00 $10,215.00 $3,357.61 $785.26 $5,720.00 Employees are paid weekly on Friday. The following paydays occurred during this quarter: July August September 5 weekly paydays 4 weekly paydays 4 weekly paydays Taxes withheld for the 13 paydays in the third quarter follow: Employees' Weekly Weekly Federal Income Tax FICA Taxes Withheld on Wages FICA Taxes on Tips OASDI HI OASDI HI $440.00 per week Employees' $209.56 $49.01 Employees' $48.72 $11.39 Employer's 209.56 49.01 Employer's 48.72 11.39 Based on the information given, complete Form 941 on the following pages for Diane R. Peters. Phone number: (901) 555-7959 Date filed: October 31, 20-- Note: Lines 5a and 5c of Form 941, tax on total taxable wages, are computed by multiplying by the combined tax rate for both employer and employee. Small differences due to rounding may occur between this total and the total taxes withheld from employees each pay period and the amount of the employer's taxes calculated each pay period. This difference is reported on line 7 as a deduction or an addition as "Fractions of Cents." If required, round your answers to nearest cent. Use a minus sign to indicate a deduction. If line 7 is zero, for grading purposes only, enter a zero. Assume that company deposits taxes on monthly basis. Hint: Line 7 instructions. Fill in Form 941 through line 6, and then fill in Part 2, line 16 or Schedule B. Take that information and fill in line 13. Lines 12 and 13 must equal. If the amounts are not the same, correct by entering amount to make equal on line 7. Line 7 differences are caused by how calculations are made on Form 941 and the amounts withheld from employee's earning plus the employer's payroll tax amounts each pay. Form 941 for 20--: (Rev. January 2019) 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 3 6 0 7 Name (not your trade name) DIANE R. PETERS Trade name (if any) BAYVIEW INN Address 404 UNION AVE. Number Street Suite or room number MEMPHIS TN 38112 City State ZIP code Foreign country name Foreign province/county Foreign postal code Report for this Quarter of 20-- (Select one.) Go to www.irs.gov/Form941 for instructions and the latest information. 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 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 0.124 = 5b Taxable social security tips . . . . . . . . x 0.124 = 5c Taxable Medicare wages & tips . . . . . x 0.029 = 5d Taxable wages & tips subject to Additional Medicare Tax withholding x 0.009 = 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 Qualified small business payroll tax credit for increasing research activities. Attach Form 8974 11 12 Total taxes after adjustments and credits. Subtract line 11 from line 10 12 13 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 . . 13 14 Balance due. If line 12 is more than line 13, enter the difference and see instructions . . . . . . . . . . . . . . . . . . . . 14 15 Overpayment. If line 13 is more than line 12, enter the difference Check 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 Form 941 (Rev. 1-2019) Name (not your trade name) Employer identification number (EIN) DIANE R. PETERS 00-0003607 Part 2: Tell us about your deposit schedule and tax liability for this quarter. If you are unsure about whether you are a monthly schedule depositor or a semiweekly schedule depositor, see section 11 of Pub. 15. 16 Check one: a. 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. b. 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. Tax liability: Month 1 Month 2 Month 3 Total liability for quarter Total must equal line 12. c. You were a semiweekly schedule depositor for any part of this quarter. Complete Schedule B (Form 941), Report of Tax Liability for Semiweekly Schedule Depositors, and attach it to Form 941. Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank. 17 If your business has closed or you stopped paying wages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Check here, and 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 . . . . . . . . . . . . . . . . Check here. Part 4: May we speak with your third-party designee? 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. Designee's name and phone number Select a 5-digit Personal Identification Number (PIN) to use when talking to the IRS. Part 5: Sign here. You MUST complete both pages of Form 941 and SIGN it. 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. Sign your name here Diane R. Peters Print your name here Diane R. Peters Print your title here Owner Date 10/31/-- Best daytime phone 901-555-7959 Paid Preparer Use Only Check if you are self-employed . . . . Preparer's name PTIN Preparer's signature Date / / Firm's name (or yours if self-employed) EIN Address Phone City State ZIP code Page 2 Form 941 (Rev. 1-2019) Source: Internal Revenue Service

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