b Employer’s name, address, and ZIP code
c Kind of Payer (Check one)
941/941-SS
Military
943
944
CT-1
Hshld. emp.
Medicare govt. emp.
Kind of Employer (Check one)
None apply
501c non-govt.
State/local non-501c
State/local 501c
Federal govt.
Third-party sick pay
Complete boxes h, i, or j only if incorrect on last form filed.
h Employer’s originally reported EIN
i Incorrect establishment number
j Employer’s incorrect state ID number
Total of amounts previously reported
Total of corrected amounts
Total of amounts previously reported
Total of corrected amounts
1 Wages, tips, other compensation
1 Wages, tips, other compensation
2 Federal income tax withheld
2 Federal income tax withheld
3 Social security wages
3 Social security wages
4 Social security tax withheld
4 Social security tax withheld
5 Medicare wages and tips
5 Medicare wages and tips
6 Medicare tax withheld
6 Medicare tax withheld
7 Social security tips
7 Social security tips
8 Allocated tips
8 Allocated tips
9
9
10 Dependent care benefits
10 Dependent care benefits
11 Nonqualified plans
11 Nonqualified plans
12a Deferred compensation
12a Deferred compensation
14 Income tax withheld by third-party sick pay payer
14 Income tax withheld by third-party sick pay payer
12b
12b
16 State wages, tips, etc.
16 State wages, tips, etc.
17 State income tax
17 State income tax
18 Local wages, tips, etc.
18 Local wages, tips, etc.
19 Local income tax
19 Local income tax
Has an adjustment been made on an employment tax return filed with the Internal Revenue Service?
Yes
No
If “Yes,” give date the return was filed:
Under penalties of perjury, I declare that I have examined this return, including accompanying documents, and, to the best of my knowledge and belief, it is true, correct, and complete.
