During the third calendar quarter of 20--, the Beechtree Inn, owned by Dawn Smedley, 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.

Employee		Salary or Wage		Quarter's Wages		Quarter's Tips		Quarter's OASDI		Quarter's HI		Quarter's FIT
Jennifer Pasco		$104,000/year		$26,000.00				$1,612.00		$337.00		$1,980.00
Shelby Toland		78,000/year		19,500.00				1,209.00		282.75		1,290.00
Casey Riordan		800/week		10,400.00		$3,240.90		845.78		197.73		600.00
Howard Cohen		650/week		8,450.00		3,493.10		740.48		173.29		630.00
Rebecca Somerville		675/week		8,775.00		3,640.30		769.73		180.05		690.00
Matthew Chalfont		750/week		9,750.00		3,704.00		834.21		195.13		540.00
Sean Matthews		750/week		9,750.00				604.50		141.44		910.00
Holly Perry		600/week		7,800.00				483.60		113.10		653.00
Margaret Levine		750/week		9,750.00				604.50		141.44		364.00
Mary Bullen		600/week		7,800.00				483.60		113.10		559.00
				$117,975.00		$14,078.30		$8,187.40		$1,915.03		$8,216.00

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' Federal Income Tax		Weekly FICA Taxes Withheld on Wages					Weekly FICA Taxes on Tips
		OASDI			HI		OASDI			HI
$632 per week		Employees'	$562.65		$131.61		Employees'	$67.15		$15.70
		Employer's	562.65		131.59		Employer's	67.14		15.70

Based on the information given, complete Form 941 on the following pages for Dawn Smedley. 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 7a as a deduction or an addition as "Fractions of Cents."

If required, round your answers to the nearest cent.

Form 941 for 20--: (Rev. January 2017)

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)

DAWN SMEDLEY

Trade name (if any)

BEECHTREE 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.)

Instructions and prior year forms are available at www.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), 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. 1-2017)

Name (not your trade name)	Employer identification number (EIN)
DAWN SMEDLEY	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 (line 10 if the prior quarter was the fourth quarter of 2016) 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 (line 10 if the prior quarter was the fourth quarter of 2016) 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

Dawn Smedley

Print your name here

Dawn Smedley

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. 1-2017) Source: Internal Revenue Service