Semimonthly Paydays Gross and Taxable Wages FICA Withheld OASDI FICA Withheld HI Federal Income Tax Withheld 1/15 $24,500 $1,519.00 $355.25 $3,185.00 1/31 23,985 1,487.07 347.78 3,090.00 2/15 25,190 1,561.78 365.26 3,410.00 2/28 25,530 1,582.86 370.19 3,497.00 3/15 24,950 1,546.90 361.78 3,385.00 3/29 25,100 1,556.20 363.95 3,400.00 $149,255 $9,253.81 $2,164.21 $19,967.00

(Rev. January 2017) Department of the Treasury Internal Revenue Service Report for this Quarter... (Select one.) Employer identification number (EIN) 00 - 0001462 V January, February, March Name (not your trade name) STEVE HAZELTON Calendar year 20-- (Also check quarter) Use this schedule to show your TAX LIABILITY for the quarter; don't use it to show your deposits. When you file this form with Form 941 or Form 941-ss, don't change your tax liability by adjustments reported on any Forms 941-X or 944-X. You must fill out this form and attach it to Form 941 or Form 941-SS if you're a semiweekly schedule depositor or became one because your accumulated tax liability on any day was $100,000 or more. Write your daily tax liability on the numbered space that corresponds to the date wages were paid. See Section 11 in Pub. 15 for details. Month 1 17 Tax liability for Month 1 13,693.20 6,933.5 X 6,759.7 ! Tax liability for Month 2 14,667.18 7,403.1 7,264.08 HII NITI Month 3 Tax liability for Month 3 14,442.66 7,240.3 x 7,202.36