Salary or	Quarter's	Quarter's	Quarter's	Quarter's	Quarter's
Employee	Wage	Wages	Tips	OASDI	HI	FIT
Grant Frazier	$74,880/year		$18,720.00				$1160.64		$271.44		$843.00
Joseph LaVange	17,680/year		4,420.00				274.04		64.09		548.00
Susanne Ayers	255/week		3,315.00		$2,278.10		346.77		81.10		519.00
Howard Cohen	220/week		2,860.00		2,568.20		336.55		78.71		615.00
Lee Soong	260/week		3,380.00		2,648.10		373.74		87.41		645.00
Mary Yee	250/week		3,250.00		2,741.10		371.45		86.87		665.00
Helen Woods	325/week		4,225.00				261.95		61.26		426.00
Koo Shin	320/week		4,160.00				257.92		60.32		534.00
Aaron Abalis	400/week		5,200.00				322.40		75.40		686.00
David Harad	170/week		2,210.00				137.02		32.05		237.00
			$51,740.00		$10,235.50		$3,842.48		$898.65		$5,718.00

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'	Weekly	Weekly
Federal Income Tax	FICA Taxes Withheld on Wages	FICA Taxes on Tips
	OASDI	HI	OASDI	HI
$439.85 per week	Employees'	$246.76	$57.71	Employees'	$48.82	$11.42
	Employer's	246.76	57.71	Employer's	48.82	11.42

11d	Nonrefundable portion of credit for qualified sick and family leave wages for leave taken after March 31, 2021, and before October 1, 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11d	fill in the blank 27
11e	Nonrefundable portion of COBRA premium assistance credit (see instructions for applicable quarter)	11e	fill in the blank 28
11f	Number of individuals provided COBRA premium assistance fill in the blank 29
11g	Total nonrefundable credits. Add lines 11a, 11b, 11d, and 11e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	11g	fill in the blank 30
12	Total taxes after adjustments and nonrefundable credits. Subtract line 11g from line 10 . . . . . . . . . . . . .	12	fill in the blank 31
13a	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 . . . . . . . . . . .	13a	fill in the blank 32
13b	Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	13b	fill in the blank 33
13c	Refundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13c	fill in the blank 34
13d	Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	13d	fill in the blank 35
13e	Refundable portion of credit for qualified sick and family leave wages for leave taken after March 31, 2021, and before October 1, 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13e	fill in the blank 36
13f	Refundable portion of COBRA premium assistance credit (see instructions for applicable quarter) . .	13f	fill in the blank 37
13g	Total deposits and refundable credits. Add lines 13a, 13c, 13e, and 13f . . . . . . . . . . . . . . . . . . . . . . . . . . .	13g	fill in the blank 38
13h	Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	13h	fill in the blank 39
13i	Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	13i	fill in the blank 40
14	Balance due. If line 12 is more than line 13g, enter the difference and see instructions . . . . . . . . . . . . . . . . . .	14	fill in the blank 41

16 Check one:

abc

a.

Line 12 on this return is less than $2,500 or line 12 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 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're a monthly schedule depositor, complete the deposit schedule below; if you're 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	fill in the blank 44
	Month 2	fill in the blank 45
	Month 3	fill in the blank 46
Total liability for quarter	fill in the blank 47	Total must equal line 12.

19	Qualified health plan expenses allocable to qualified sick leave wages for leave taken before April 1, 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19	fill in the blank 48
20	Qualified health plan expenses allocable to qualified family leave wages for leave taken before April 1, 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20	fill in the blank 49
21	Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	21	fill in the blank 50
22	Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	22	fill in the blank 51
23	Qualified sick leave wages for leave taken after March 31, 2021, and before October 1, 2021 . . . . . . . .	23	fill in the blank 52
24	Qualified health plan expenses allocable to qualified sick leave wages reported on line 23 . . . . . . . . . .	24	fill in the blank 53
25	Amounts under certain collectively bargained agreements allocable to qualified sick leave wages reported on line 23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25	fill in the blank 54
26	Qualified family leave wages for leave taken after March 31, 2021, and before October 1, 2021 . . . . . .	26	fill in the blank 55
27	Qualified health plan expenses allocable to qualified family leave wages reported on line 26 . . . . . . . .	27	fill in the blank 56
28	Amounts under certain collectively bargained agreements allocable to qualified family leave wages reported on line 26 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
28	fill in the blank 57