# 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

14 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) Wages, tips, and other compensation .... 2 79,750.17 9,570 Check and go to line Federal income tax withheld from wages, tips, and other compensation ...... If no wages, tips, and other compensation are subject to social security or Medicare tax Column 1 Column 2 Taxable social security wages ...... 79,750.17 x 0.124 = 9,889.02 Taxable social security tips ........ x 0.124 = xable Medicare wages & tips ...... 79,750.17 x 0.029 = 2,312.75 Taxable wages & tips subject to Additional Medicare Tax withholding x 0.009 = Add Column 2 from lines 5a, 5b, 5c, and 5d ................. ............ 5e 12,201.78 Section 3121(q) Notice and Demand-Tax due on unreported tips (see instructions) ......... 21,771.78 ) 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 .................. Total taxes after adjustments. Combine lines 6 through 9 ........ 10 11 21,771.78 X 21,771.783 x Qualified small business payroll tax credit for increasing research activities. Attach Form 8974 .. 0.05 x Total taxes after adjustments and credits. Subtract line 11 from line 10. . - tal deposits for this quarter, including overpayment applied from a prior quarter and overpayments 13 splied 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. Send a refun Ne You MUST complete both pages of Form 941 and SIGN it. rivacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher. Cat. No. 170017 Form 941 (Rev. 1-2