Please complete all required lines

1. Employees are paid weekly on Friday. The following paydays occurred during this quarter:

2. 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
   $700 per week	Employees'	$500.65	$117.11	Employees'	$48.07	$11.24
   	Employer's	500.65	117.09	Employer's	48.07	11.24

   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."

   Hint: Line 7 instructions. Fill in Form 941 through line 6, then fill in Part 2, line 16, item b. Take that information and fill in line 13. Note that 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.

   _Form941 for 20--: ^{(Rev. January 2018)}

   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.)

   July, August, September

   • January, February, March
   • April, May, June
   • July, August, September
   • October, November, December

   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. 1-2018)