# of employees for pay period that included September 12 = 14 employees Wages paid third quarter = $79,750.17 Federal income tax withheld in the third quarter = $9,570.00 Taxable social security and Medicare wages = $79,750.17 Total tax deposits for the quarter = $21,771.83

Add Column 2 from lines 5a, 5b, 5c, and 5d ......... 12,201.77 Section 3121(q) Notice and Demand-Tax due on unreported tips (see instructions) ............ n g 5 . . . . . . . . . . . . 21,771.77 . . . . . . . . . . . . . . . . . . . . . . . . . Total taxes before adjustments. Add lines 3, 5e, and 5f.. Current quarter's adjustment for fractions of cents . Current quarter's adjustment for sick pay ..... ......... Current quarter's adjustments for tips and group-term life insurance .......... - tal taxes after adjustments. Combine lines 6 through 9 ........ ........... 21,771.77 Qualified small business payroll tax credit for increasing research activities. Attach Form 8974 .. 21,770 x Total taxes after adjustments and credits. Subtract line 11 from line 10.. 0.05 x 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 .. Balance due. If line 12 is more than line 13, enter the difference and see instructions ......... ... 14 Overpayment. If line 13 is more than line 12, enter the difference Check one: o Apply to next return. O Send a refund You MUST complete both pages of Form 941 and SIGN it. Ne