Form 941-X:
(Rev. April 2017)
Adjusted Employer's QUARTERLY Federal Tax Return or Claim for Refund
Department of the Treasury — Internal Revenue Service
OMB No. 1545-0029
Employer identification number
(EIN)
—
Name (not your trade name)
Trade name (if any)
Address
Number Street Suite or room number
City State
ZIP code
Foreign country name
Foreign province/county
Foreign postal code
Read the separate instructions before completing this form. Use this form to correct
errors you made on Form 941 or 941-SS. Use a separate Form 941-X for each quarter
that needs correction. Type or print within the boxes. You MUST complete all three
pages. Don't attach this form to Form 941 or 941-SS.
Return You're Correcting ...
Check the type of return you're correcting.
941
941-SS
Check the ONE quarter you're correcting.
1: January, February, March
2: April, May, June
3: July, August, September
4: October, November, December
Enter the calendar year of the
quarter you're correcting.
(YYYY)
Enter the date you discovered errors.
/ /
(MM / DD / YYYY)
Part 1: Select ONLY one process. See page 4 for additional guidance.
1.
Adjusted employment tax return. Check this box if you underreported amounts. Also
check this box if you overreported amounts and you would like to use the adjustment
process to correct the errors. You must check this box if you're correcting both
underreported and overreported amounts on this form. The amount shown on line 21, if
less than zero, may only be applied as a credit to your Form 941, Form 941-SS, or
Form 944 for the tax period in which you're filing this form.
2.
Claim. Check this box if you overreported amounts only and you would like to use the
claim process to ask for a refund or abatement of the amount shown on line 21. Don't
check this box if you're correcting ANY underreported amounts on this form.
Part 2: Complete the certifications.
3.
I certify that I've filed or will file Forms W-2, Wage and Tax Statement, or Forms W-2c, Corrected Wage and Tax Statement,
as required.
Note: If you're correcting underreported amounts only, go to Part 3 on page 2 and skip lines 4 and 5. If you're correcting overreported
amounts, for purposes of the certifications on lines 4 and 5, Medicare tax doesn't include Additional Medicare Tax. Form 941-X can't be
used to correct overreported amounts of Additional Medicare Tax unless the amounts weren't withheld from employee wages or an
adjustment is being made for the current year.
4.
If you checked line 1 because you're adjusting overreported amounts, check all that apply. You must check at least one box.
I certify that:
a. I repaid or reimbursed each affected employee for the overcollected federal income tax or Additional Medicare Tax for the current
year and the overcollected social security tax and Medicare tax for current and prior years. For adjustments of employee social
security tax and Medicare tax overcollected in prior years, I have a written statement from each affected employee stating that he
or she hasn't claimed (or the claim was rejected) and won't claim a refund or credit for the overcollection.
b.
The adjustments of social security tax and Medicare tax are for the employer’s share only. I couldn't find the affected employees or
each affected employee didn't give me a written statement that he or she hasn't claimed (or the claim was rejected) and won't
claim a refund or credit for the overcollection.
c.
The adjustment is for federal income tax, social security tax, Medicare tax, or Additional Medicare Tax that I didn't withhold from
employee wages.
5.
If you checked line 2 because you're claiming a refund or abatement of overreported employment taxes, check all that apply.
You must check at least one box.
I certify that:
a.
I repaid or reimbursed each affected employee for the overcollected social security tax and Medicare tax. For claims of employee
social security tax and Medicare tax overcollected in prior years, I have a written statement from each affected employee stating
that he or she hasn't claimed (or the claim was rejected) and won't claim a refund or credit for the overcollection.
b.
I have a written consent from each affected employee stating that I may file this claim for the employee’s share of social security
tax and Medicare tax. For refunds of employee social security tax and Medicare tax overcollected in prior years, I also have a
written statement from each affected employee stating that he or she hasn't claimed (or the claim was rejected) and won't claim a
refund or credit for the overcollection.
c.
The claim for social security tax and Medicare tax is for the employer’s share only. I couldn't find the affected employees; or each
affected employee didn't give me a written consent to file a claim for the employee’s share of social security tax and Medicare tax;
or each affected employee didn't give me a written statement that he or she hasn't claimed (or the claim was rejected) and won't
claim a refund or credit for the overcollection.
d.
The claim is for federal income tax, social security tax, Medicare tax, or Additional Medicare Tax that I didn't withhold from
employee wages.
Next
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For Paperwork Reduction Act Notice, see the instructions.
www.irs.gov/Form941X Cat. No. 17025J
Form
941-X (Rev. 4-2017)
