Fill in a Valid IRS 941 Form

Report for this Quarter of 2023

(Check one.)

1: January, February, March

2: April, May, June

3: July, August, September

4: October, November, December

Go to www.irs.gov/Form941 for instructions and the latest information.

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Check and go to line 6.

*Include taxable qualified sick and family leave wages paid in this quarter of 2023 for leave taken after March 31, 2021, and before October 1, 2021, on line 5a. Use lines 5a(i) and 5a(ii) only for taxable qualified sick and family leave wages paid in this quarter of 2023 for leave taken after March 31, 2020, and before April 1, 2021.

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11c Reserved for future use . . . . . . . . . . . . . . . . . . . . . . 11c

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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

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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

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14Balance due. If line 12 is more than line 13g, enter the difference and see instructions . . . 14

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16 Check one:

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.

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.

Name (not your trade name)

Employer identification number (EIN)

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17 If your business has closed or you stopped paying wages . . . . . . . . . . . . . . .

Check here, and

enter the final date you paid wages

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; also attach a statement to your return. See instructions.

18 If you’re a seasonal employer and you don’t have to file a return for every quarter of the year . . .

Check here.

19Qualified health plan expenses allocable to qualified sick leave wages for leave taken before April 1, 2021

20Qualified health plan expenses allocable to qualified family leave wages for leave taken before April 1, 2021

23Qualified sick leave wages for leave taken after March 31, 2021, and before October 1, 2021

24Qualified health plan expenses allocable to qualified sick leave wages reported on line 23

25Amounts under certain collectively bargained agreements allocable to qualified sick

leave wages reported on line 23 . . . . . . . . . . . . . . . . . . .

26Qualified family leave wages for leave taken after March 31, 2021, and before October 1, 2021

27Qualified health plan expenses allocable to qualified family leave wages reported on line 26

28Amounts under certain collectively bargained agreements allocable to qualified family leave wages reported on line 26 . . . . . . . . . . . . . . . . . . .

Sign your name here

Date

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Print your name here

Print your title here

Best daytime phone

Paid Preparer Use Only

Preparer’s name

Preparer’s signature

Firm’s name (or yours if self-employed)

Address

City

State

Check if you’re self-employed . . .

ZIP code

Purpose of Form

Complete Form 941-V if you’re making a payment with Form 941. We will use the completed voucher to credit your payment more promptly and accurately, and to improve our service to you.

Making Payments With Form 941

To avoid a penalty, make your payment with Form 941 only if:

•Your total taxes after adjustments and nonrefundable credits (Form 941, line 12) for either the current quarter or the preceding quarter are less than $2,500, you didn’t incur a $100,000 next-day deposit obligation during the current quarter, and you’re paying in full with a timely filed return; or

•You’re a monthly schedule depositor making a payment in accordance with the Accuracy of Deposits Rule. See section 11 of Pub. 15 for details. In this case, the amount of your payment may be $2,500 or more.

Otherwise, you must make deposits by electronic funds transfer. See section 11 of Pub. 15 for deposit instructions. Don’t use Form 941-V to make federal tax deposits.

▲! Use Form 941-V when making any payment with Form 941. However, if you pay an amount with

CAUTION Form 941 that should’ve been deposited, you may be subject to a penalty. See Deposit Penalties in section 11 of Pub. 15.

Specific Instructions

Box 1—Employer identification number (EIN). If you don’t have an EIN, you may apply for one online by visiting the IRS website at www.irs.gov/EIN. You may also apply for an EIN by faxing or mailing Form SS-4 to the IRS. If you haven’t received your EIN by the due date of Form 941, write “Applied For” and the date you applied in this entry space.

Box 2—Amount paid. Enter the amount paid with Form 941.

Box 3—Tax period. Darken the circle identifying the quarter for which the payment is made. Darken only one circle.

Box 4—Name and address. Enter your name and address as shown on Form 941.

•Enclose your check or money order made payable to “United States Treasury.” Be sure to enter your

EIN, “Form 941,” and the tax period (“1st Quarter 2023,” “2nd Quarter 2023,” “3rd Quarter 2023,” or “4th Quarter 2023”) on your check or money order. Don’t send cash.

Don’t staple Form 941-V or your payment to Form 941 (or to each other).

•Detach Form 941-V and send it with your payment

and Form 941 to the address in the Instructions for Form 941.

Note: You must also complete the entity information above Part 1 on Form 941.

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on Form 941 to carry out the Internal Revenue laws of the United States. We need it to figure and collect the right amount of tax. Subtitle C, Employment Taxes, of the Internal Revenue Code imposes employment taxes on wages and provides for income tax withholding. Form 941 is used to determine the amount of taxes that you owe. Section 6011 requires you to provide the requested information if the tax is applicable to you. Section 6109 requires you to provide your identification number. If you fail to provide this information in a timely manner, or provide false or fraudulent information, you may be subject to penalties.

You’re not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books and records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law.

Generally, tax returns and return information are confidential, as required by section 6103. However, section 6103 allows or requires the IRS to disclose or give the information shown on your tax return to others as described in the Code. For example, we may disclose your tax information to the Department of

Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

The time needed to complete and file Form 941 will vary depending on individual circumstances. The estimated average time is:

Recordkeeping . . . . . . . . . . 22 hr., 28 min.

If you have comments concerning the accuracy of these time estimates or suggestions for making Form 941 simpler, we would be happy to hear from you. You can send us comments from www.irs.gov/FormComments. Or you can send your comments to Internal Revenue Service, Tax Forms and Publications Division, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224. Don’t send Form 941 to this address. Instead, see Where Should You File? in the Instructions for Form 941.