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 .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, 944-X (PR), 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 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. 1-2015)

Name (not your trade name)	Employer identification number (EIN)
QUALITY REPAIRS	00-0004701

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 Pub. 15 (Circular E), section 11.

14 Check one:

a.

Line 10 on this return is less than $2,500 or line 10 on the return for the prior quarter was less than $2,500, and you did not incur a $100,000 next-day deposit obligation during the current quarter. If line 10 for the prior quarter was less than $2,500 but line 10 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 10.

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.

15

If your business has closed or you stopped paying wages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Check here, and
enter the final date you paid wages	/ /	.

16

If you are a seasonal employer and you do not 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.

No

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

Print your name here

Print your title here

Date

1/31/17

Best daytime phone

501-555-7331

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. 1-2015) Source: Internal Revenue Service

c. Employer's Report of State Income Tax Withheld for the quarter, due on or before January 31, 2017.

EMPLOYER'S REPORT OF STATE INCOME TAX WITHHELD

(DO NOT WRITE IN THIS SPACE)

IMPORTANT, PLEASE REFER TO THIS NUMBER IN ANY CORRESPONDENCE

WITHHOLDING IDENTIFICATION NUMBER

MONTH OF OR QUARTER ENDING

00-0-3301

DEC. 20--

1.

GROSS PAYROLL THIS PERIOD

$

IF YOU ARE A SEASONAL EMPLOYER AND THIS IS YOUR FINAL REPORT FOR THIS

QUALITY REPAIRS 10 SUMMIT SQUARE CITY, STATE 00000-0000

2.

STATE INCOME TAX WITHHELD

$

SEASON, CHECK HERE

AND SHOW THE NEXT MONTH IN WHICH YOU WILL PAY WAGES

3.

ADJUSTMENT FOR PREVIOUS PERIOD(S). (ATTACH STATEMENT)

$

4.

TOTAL ADJUSTED TAX (LINE 2 PLUS OR MINUS LINE 3)

$

IF NAME OR ADDRESS IS INCORRECT, PLEASE MAKE CORRECTIONS. THIS REPORT MUST BE RETURNED EVEN IF NO AMOUNT HAS BEEN WITHHELD

5.

PENALTY (35% OF LINE 4)

$

6.

INTEREST

$

Under penalties prescribed by law, I hereby affirm that to the best of my knowledge and belief this return, including any accompanying schedules and statements, is true and complete. If prepared by a person other than taxpayer, his affirmation is based on all information of which he has any knowledge.

7.

TOTAL AMOUNT DUE AND PAYABLE

$

SIGNATURE:

STUDENT

TITLE:

President

DATE:

1/31/17

MAIL THIS REPORT WITH CHECK OR MONEY ORDER PAYABLE TO THE DEPT. OF REVENUE ON OR BEFORE DUE DATE TO AVOID PENALTY.