Form 941-X, Adjusted Employer’s QUARTERLY Federal Tax Return or Claim for Refund Instructions

Provide the street number, street name, and any suite or room number for the address.

Enter the official name of the business, not its trade name.

Enter the first two digits of the Employer Identification Number (EIN).

Enter the last seven digits of the Employer Identification Number (EIN).

Enter the number corresponding to the quarter being corrected.

Enter the calendar year for which corrections are being made.

Please enter the four-digit calendar year for the quarter being corrected.

Check this box if you 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, and for prior-year overcollections you have a written statement from each employee that they haven’t claimed (or their claim was rejected) and won’t claim a refund or credit for the overcollection. Fill only if the 'Adjusted employment tax return' is 'Yes'. Fill only if 'Adjusted employment tax return' is 'Yes'.

Check this box if the adjustments of social security tax and Medicare tax are for the employer’s share only because you couldn’t find the affected employees or they didn’t provide a written statement that they haven’t claimed (or their claim was rejected) and won’t claim a refund or credit for the overcollection. Fill only if the 'Adjusted employment tax return' is 'Yes'. Fill only if 'Adjusted employment tax return' is 'Yes'.

Check this box if the adjustment is for federal income tax, social security tax, Medicare tax, or Additional Medicare Tax that you didn’t withhold from employee wages. Fill only if the 'Adjusted employment tax return' is 'Yes'. Fill only if 'Adjusted employment tax return' is 'Yes'.

Check this box if you repaid or reimbursed each affected employee for the overcollected social security and Medicare tax, and for prior years, you have a written statement from employees confirming they haven't claimed or won't claim a refund. Fill only if 'Claim' is 'Yes'.

Check this box if you have a written consent from each affected employee stating that you may file this claim for their share of social security and Medicare tax, and for prior years, you have a written statement confirming they haven't claimed or won't claim a refund. Fill only if 'Claim' is 'Yes'.

Check this box if the claim for social security and Medicare tax is for the employer's share only, and you couldn't find affected employees or get their consent or statement regarding claiming a refund or credit. Fill only if 'Claim' is 'Yes'.

Check this box if the claim is for federal income tax, social security tax, Medicare tax, or Additional Medicare Tax that you did not withhold from employee wages. Fill only if 'Claim' is 'Yes'.

Enter the city of the employer’s domestic mailing address.

Provide the state for the address.

Provide the ZIP code for the address.

Please enter the four-digit calendar year for which corrections are being made.

Please provide the number of the quarter being corrected.

Specify the quarter being corrected, which can be 1, 2, 3, or 4.

Provide the calendar year for which corrections are being made.

Enter the quarter being corrected, which should be a number from 1 to 4.

Enter the four-digit calendar year that is being corrected.

Check this box if any corrections you entered on a line include both underreported and overreported amounts, which require explanation on line 43.

Check this box if any corrections involve reclassified workers, which require explanation on line 43.

Provide a detailed explanation of how the corrections were determined for this quarter.

Provide the month in which the errors were discovered.

Enter the month you discovered the errors.

Enter the day you discovered the errors.

Provide the day and year in which the errors were discovered.

Enter the first two digits of the Employer Identification Number.

Enter the last seven digits of the Employer Identification Number.

Please enter the first two digits of your Employer Identification Number (EIN).

Please enter the last seven digits of your Employer Identification Number (EIN).

Enter the first two digits of the Employer Identification Number.

Enter the last seven digits of the Employer Identification Number.

Please enter the first two digits of your Employer Identification Number (EIN).

Please enter the last seven digits of your Employer Identification Number (EIN).

Provide the name of the foreign country for the address.

Provide the name of the foreign province or county for the address.

Provide the foreign postal code for the address.

Enter the total corrected amount of qualified family leave wages for all employees, in dollars (Column 1, Line 10).

Enter the total corrected amount of qualified family leave wages for all employees, in cents (Column 1, Line 10).

Enter the amount of qualified family leave wages originally reported or previously corrected for all employees, in dollars (Column 2, Line 10).

Enter the amount of qualified family leave wages originally reported or previously corrected for all employees, in cents (Column 2, Line 10).

Enter the difference in qualified family leave wages, in dollars. If this is a negative number, use a minus sign (Column 3, Line 10).

Enter the difference in qualified family leave wages, in cents. If this is a negative number, use a minus sign (Column 3, Line 10).

Enter the tax correction amount for qualified family leave wages, in dollars (Column 4, Line 10).

Enter the tax correction amount for qualified family leave wages, in cents (Column 4, Line 10).

Enter the total corrected dollar amount of taxable social security tips for all employees.

Enter the cents for the total corrected amount of taxable social security tips for all employees.

Enter the originally reported or previously corrected dollar amount of taxable social security tips for all employees.

Enter the cents for the originally reported or previously corrected amount of taxable social security tips for all employees.

Enter the dollar amount representing the difference between the total corrected taxable social security tips and the amount originally reported.

Enter the cents representing the difference between the total corrected taxable social security tips and the amount originally reported.

Enter the dollar amount for the tax correction related to taxable social security tips.

Enter the cents for the tax correction related to taxable social security tips.

Enter the total corrected amount of taxable Medicare wages and tips for all employees, representing the dollar portion of the value.

Enter the total corrected amount of taxable Medicare wages and tips for all employees, representing the cents portion of the value.

Enter the amount of taxable Medicare wages and tips originally reported or previously corrected for all employees, representing the dollar portion of the value.

Enter the amount of taxable Medicare wages and tips originally reported or previously corrected for all employees, representing the cents portion of the value.

Enter the difference between the corrected and originally reported taxable Medicare wages and tips, representing the dollar portion of the value.

Enter the difference between the corrected and originally reported taxable Medicare wages and tips, representing the cents portion of the value.

Enter the tax correction amount for taxable Medicare wages and tips, calculated by multiplying the difference in column 3 by 0.029, representing the dollar portion of the value.

Enter the tax correction amount for taxable Medicare wages and tips, calculated by multiplying the difference in column 3 by 0.029, representing the cents portion of the value.

Enter the total corrected dollar amount of taxable wages and tips subject to Additional Medicare Tax withholding.

Enter the total corrected cents amount of taxable wages and tips subject to Additional Medicare Tax withholding.

Enter the dollar amount of taxable wages and tips originally reported or previously corrected, subject to Additional Medicare Tax withholding.

Enter the cents amount of taxable wages and tips originally reported or previously corrected, subject to Additional Medicare Tax withholding.

Enter the dollar amount of the difference between the corrected and originally reported taxable wages and tips.

Enter the cents amount of the difference between the corrected and originally reported taxable wages and tips.

Enter the dollar amount for the tax correction related to Additional Medicare Tax withholding.

Enter the cents amount for the tax correction related to Additional Medicare Tax withholding.

Enter the total corrected dollar amount of tax due on unreported tips.

Enter the total corrected cents amount of tax due on unreported tips.

Enter the dollar amount of tax due on unreported tips as originally reported or previously corrected.

Enter the cents amount of tax due on unreported tips as originally reported or previously corrected.

Enter the dollar amount representing the difference in tax due on unreported tips.

Enter the cents amount representing the difference in tax due on unreported tips.

Enter the dollar amount for the tax correction due to unreported tips, which should be copied from Column 3.

Enter the cents amount for the tax correction due to unreported tips, which should be copied from Column 3.

Provide the dollar portion of the total corrected tax adjustments for all employees.

Provide the cents portion of the total corrected tax adjustments for all employees.

Provide the dollar portion of the tax adjustments amount originally reported or previously corrected for all employees.

Provide the cents portion of the tax adjustments amount originally reported or previously corrected for all employees.

Provide the dollar portion of the calculated difference for tax adjustments.

Provide the cents portion of the calculated difference for tax adjustments.

Provide the dollar portion of the final tax correction amount for tax adjustments.

Provide the cents portion of the final tax correction amount for tax adjustments.

Enter the total corrected amount in dollars for the qualified small business payroll tax credit for increasing research activities.

Enter the total corrected amount in cents for the qualified small business payroll tax credit for increasing research activities.

Enter the amount originally reported or as previously corrected in dollars for the qualified small business payroll tax credit for increasing research activities.

Enter the amount originally reported or as previously corrected in cents for the qualified small business payroll tax credit for increasing research activities.

Enter the difference in dollars for the qualified small business payroll tax credit for increasing research activities.

Enter the difference in cents for the qualified small business payroll tax credit for increasing research activities.

Enter the tax correction amount in dollars for the qualified small business payroll tax credit for increasing research activities.

Enter the tax correction amount in cents for the qualified small business payroll tax credit for increasing research activities.

Enter the dollar amount of the total corrected nonrefundable credit for qualified sick and family leave wages.

Enter the cents amount of the total corrected nonrefundable credit for qualified sick and family leave wages.

Enter the dollar amount of the nonrefundable credit for qualified sick and family leave wages that was originally reported or previously corrected.

Enter the cents amount of the nonrefundable credit for qualified sick and family leave wages that was originally reported or previously corrected.

Enter the dollar amount representing the difference in the nonrefundable credit for qualified sick and family leave wages.

Enter the cents amount representing the difference in the nonrefundable credit for qualified sick and family leave wages.

Enter the dollar amount of the tax correction for the nonrefundable credit for qualified sick and family leave wages.

Enter the cents amount of the tax correction for the nonrefundable credit for qualified sick and family leave wages.

Enter the dollar value for the reserved field in Line 18a, Column 1.

Enter the cents value for the reserved field in Line 18a, Column 1.

Enter the dollar value for the reserved field in Line 18a, Column 2.

Enter the cents value for the reserved field in Line 18a, Column 2.

Enter the dollar value for the reserved field in Line 18a, Column 3.

Enter the cents value for the reserved field in Line 18a, Column 3.

Enter the dollar value for the reserved field in Line 18a, Column 4.

Enter the cents value for the reserved field in Line 18a, Column 4.

Enter the dollar amount of the total corrected nonrefundable credit for qualified sick and family leave wages, for leave taken after March 31, 2021, and before October 1, 2021.

Enter the cents amount of the total corrected nonrefundable credit for qualified sick and family leave wages, for leave taken after March 31, 2021, and before October 1, 2021.

Enter the dollar amount of the nonrefundable credit for qualified sick and family leave wages that was originally reported or previously corrected, for leave taken after March 31, 2021, and before October 1, 2021.

Enter the cents amount of the nonrefundable credit for qualified sick and family leave wages that was originally reported or previously corrected, for leave taken after March 31, 2021, and before October 1, 2021.

Enter the dollar amount of the difference in the nonrefundable credit for qualified sick and family leave wages. If this is a negative number, use a minus sign.

Enter the cents amount of the difference in the nonrefundable credit for qualified sick and family leave wages.

Enter the dollar amount of the tax correction for the nonrefundable credit for qualified sick and family leave wages, for leave taken after March 31, 2021, and before October 1, 2021.

Enter the cents amount of the tax correction for the nonrefundable credit for qualified sick and family leave wages, for leave taken after March 31, 2021, and before October 1, 2021.

Enter the total corrected whole dollar amount for the nonrefundable COBRA premium assistance credit.

Enter the cents amount for the total corrected nonrefundable COBRA premium assistance credit.

Enter the whole dollar amount of the nonrefundable COBRA premium assistance credit that was originally reported or previously corrected.

Enter the cents amount of the nonrefundable COBRA premium assistance credit that was originally reported or previously corrected.

Enter the whole dollar amount representing the difference in nonrefundable COBRA premium assistance credit.

Enter the cents amount representing the difference in nonrefundable COBRA premium assistance credit.

Enter the whole dollar amount for the tax correction related to the nonrefundable COBRA premium assistance credit.

Enter the cents amount for the tax correction related to the nonrefundable COBRA premium assistance credit.

Enter the total corrected number of individuals who received COBRA premium assistance for all employees. Fill only if 'Total Corrected Amount Dollars', 'Total Corrected Amount Cents', 'Originally Reported Amount Dollars', 'Originally Reported Amount Cents', 'Difference Amount Dollars', 'Difference Amount Cents', 'Tax Correction Amount Dollars', 'Tax Correction Amount Cents' a COBRA premium assistance credit is reported on line 18c.

Enter the number of individuals who received COBRA premium assistance as originally reported or previously corrected for all employees. Fill only if 'Total Corrected Amount Dollars', 'Total Corrected Amount Cents', 'Originally Reported Amount Dollars', 'Originally Reported Amount Cents', 'Difference Amount Dollars', 'Difference Amount Cents', 'Tax Correction Amount Dollars', 'Tax Correction Amount Cents' a COBRA premium assistance credit is reported on line 18c.

Enter the difference between the total corrected and originally reported number of individuals who received COBRA premium assistance. If this amount is a negative number, use a minus sign. Fill only if 'Total Corrected Amount Dollars', 'Total Corrected Amount Cents', 'Originally Reported Amount Dollars', 'Originally Reported Amount Cents', 'Difference Amount Dollars', 'Difference Amount Cents', 'Tax Correction Amount Dollars', 'Tax Correction Amount Cents' a COBRA premium assistance credit is reported on line 18c.

Enter the dollar amount for the total corrected special addition to wages for federal income tax.

Enter the cents amount for the total corrected special addition to wages for federal income tax.

Enter the dollar amount for the special addition to wages for federal income tax that was originally reported or previously corrected.

Enter the cents amount for the special addition to wages for federal income tax that was originally reported or previously corrected.

Enter the dollar amount representing the difference for the special addition to wages for federal income tax.

Enter the cents amount representing the difference for the special addition to wages for federal income tax.

Enter the dollar amount for the tax correction related to the special addition to wages for federal income tax.

Enter the cents amount for the tax correction related to the special addition to wages for federal income tax.

Enter the total corrected dollar amount of special addition to wages for social security taxes for all employees.

Enter the cents portion of the total corrected amount of special addition to wages for social security taxes for all employees.

Enter the dollar amount of special addition to wages for social security taxes originally reported or previously corrected for all employees.

Enter the cents portion of the amount of special addition to wages for social security taxes originally reported or previously corrected for all employees.

Enter the dollar amount representing the difference between the total corrected amount and the previously reported amount for special addition to wages for social security taxes.

Enter the cents portion of the difference between the total corrected amount and the previously reported amount for special addition to wages for social security taxes.

Enter the dollar amount of the tax correction for the special addition to wages for social security taxes.

Enter the cents portion of the tax correction amount for the special addition to wages for social security taxes.

Enter the total corrected dollar amount of special addition to wages for Medicare taxes.

Enter the total corrected cents amount of special addition to wages for Medicare taxes.

Enter the dollar amount of special addition to wages for Medicare taxes as originally reported or previously corrected.

Enter the cents amount of special addition to wages for Medicare taxes as originally reported or previously corrected.

Enter the dollar difference between the total corrected amount and the originally reported amount of special addition to wages for Medicare taxes.

Enter the cents difference between the total corrected amount and the originally reported amount of special addition to wages for Medicare taxes.

Enter the dollar amount of the tax correction for special addition to wages for Medicare taxes.

Enter the cents amount of the tax correction for special addition to wages for Medicare taxes.

Enter the total corrected whole dollar amount for the special addition to wages for Additional Medicare Tax for all employees.

Enter the total corrected cents amount for the special addition to wages for Additional Medicare Tax for all employees.

Enter the originally reported or previously corrected whole dollar amount for the special addition to wages for Additional Medicare Tax for all employees.

Enter the originally reported or previously corrected cents amount for the special addition to wages for Additional Medicare Tax for all employees.

Enter the whole dollar difference between the total corrected amount and the originally reported amount for the special addition to wages for Additional Medicare Tax; use a minus sign if the amount is negative.

Enter the cents difference between the total corrected amount and the originally reported amount for the special addition to wages for Additional Medicare Tax; use a minus sign if the amount is negative.

Enter the whole dollar amount of the tax correction for the special addition to wages for Additional Medicare Tax.

Enter the cents amount of the tax correction for the special addition to wages for Additional Medicare Tax.

Enter the dollar amount for the combined total from lines 7 through 22 of Column 4.

Enter the cents amount for the combined total from lines 7 through 22 of Column 4.

Enter the dollar amount for the total corrected amount on line 24. This line is currently reserved for future use.

Enter the cents amount for the total corrected amount on line 24. This line is currently reserved for future use.

Enter the dollar amount of the amount originally reported or previously corrected on line 24. This line is currently reserved for future use.

Enter the cents amount of the amount originally reported or previously corrected on line 24. This line is currently reserved for future use.

Enter the dollar amount for the difference on line 24. This line is currently reserved for future use.

Enter the cents amount for the difference on line 24. This line is currently reserved for future use.

Enter the dollar amount for the tax correction on line 24. This line is currently reserved for future use.

Enter the cents amount for the tax correction on line 24. This line is currently reserved for future use.

Enter the dollar amount of the total corrected refundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021.

Enter the cents amount of the total corrected refundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021.

Enter the dollar amount originally reported or previously corrected for the refundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021.

Enter the cents amount originally reported or previously corrected for the refundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021.

Enter the dollar amount representing the difference for the refundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021.

Enter the cents amount representing the difference for the refundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021.

Enter the dollar amount of the tax correction for the refundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021.

Enter the cents amount of the tax correction for the refundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021.

Enter the dollar amount for the total corrected amount for line 26a.

Enter the cents amount for the total corrected amount for line 26a.

Enter the dollar amount for the amount originally reported or previously corrected for line 26a.

Enter the cents amount for the amount originally reported or previously corrected for line 26a.

Enter the dollar amount for the difference for line 26a.

Enter the cents amount for the difference for line 26a.

Enter the dollar amount for the tax correction for line 26a.

Enter the cents amount for the tax correction for line 26a.

Enter the dollar amount for the total corrected refundable portion of credit for qualified sick and family leave wages for leave taken after March 31, 2021, and before October 1, 2021.

Enter the cents amount for the total corrected refundable portion of credit for qualified sick and family leave wages for leave taken after March 31, 2021, and before October 1, 2021.

Enter the dollar amount for the refundable portion of credit for qualified sick and family leave wages that was originally reported or previously corrected, for leave taken after March 31, 2021, and before October 1, 2021.

Enter the cents amount for the refundable portion of credit for qualified sick and family leave wages that was originally reported or previously corrected, for leave taken after March 31, 2021, and before October 1, 2021.

Enter the dollar amount representing the difference in the refundable portion of credit for qualified sick and family leave wages for leave taken after March 31, 2021, and before October 1, 2021. Use a minus sign if the amount is negative.

Enter the cents amount representing the difference in the refundable portion of credit for qualified sick and family leave wages for leave taken after March 31, 2021, and before October 1, 2021. Use a minus sign if the amount is negative.

Enter the dollar amount for the tax correction related to the refundable portion of credit for qualified sick and family leave wages for leave taken after March 31, 2021, and before October 1, 2021.

Enter the cents amount for the tax correction related to the refundable portion of credit for qualified sick and family leave wages for leave taken after March 31, 2021, and before October 1, 2021.

Enter the whole dollar amount of the total corrected refundable portion of COBRA premium assistance credit for all employees.

Enter the cents amount of the total corrected refundable portion of COBRA premium assistance credit for all employees.

Enter the whole dollar amount of the refundable portion of COBRA premium assistance credit originally reported or previously corrected for all employees.

Enter the cents amount of the refundable portion of COBRA premium assistance credit originally reported or previously corrected for all employees.

Enter the whole dollar amount of the difference in the refundable portion of COBRA premium assistance credit.

Enter the cents amount of the difference in the refundable portion of COBRA premium assistance credit.

Enter the whole dollar amount of the tax correction for the refundable portion of COBRA premium assistance credit.

Enter the cents amount of the tax correction for the refundable portion of COBRA premium assistance credit.

Enter the total dollar amount for line 27.

Enter the cents portion of the total amount for line 27.

Enter the dollar amount of the total corrected qualified health plan expenses allocable to qualified sick leave wages for leave taken before April 1, 2021.

Enter the cents amount of the total corrected qualified health plan expenses allocable to qualified sick leave wages for leave taken before April 1, 2021, as a two-digit number.

Enter the dollar amount of the qualified health plan expenses for sick leave wages taken before April 1, 2021, as originally reported or previously corrected.

Enter the cents amount of the qualified health plan expenses for sick leave wages taken before April 1, 2021, as originally reported or previously corrected, as a two-digit number.

Enter the dollar amount of the difference in qualified health plan expenses for sick leave wages taken before April 1, 2021.

Enter the cents amount of the difference in qualified health plan expenses for sick leave wages taken before April 1, 2021, as a two-digit number.

Enter the total corrected amount of qualified health plan expenses allocable to qualified family leave wages.

Enter the two-digit cents portion of the total corrected amount of qualified health plan expenses allocable to qualified family leave wages.

Enter the amount of qualified health plan expenses allocable to qualified family leave wages originally reported or as previously corrected.

Enter the two-digit cents portion of the amount of qualified health plan expenses allocable to qualified family leave wages originally reported or as previously corrected.

Enter the difference between the total corrected amount and the amount originally reported for qualified health plan expenses allocable to qualified family leave wages.

Enter the two-digit cents portion of the difference for qualified health plan expenses allocable to qualified family leave wages.

Enter the total corrected dollar amount for all employees for line 30, which is reserved for future use.

Enter the cents portion of the total corrected amount for all employees for line 30, which is reserved for future use.

Enter the dollar amount originally reported or previously corrected for all employees for line 30, which is reserved for future use.

Enter the cents portion of the amount originally reported or previously corrected for all employees for line 30, which is reserved for future use.

Enter the dollar difference amount for line 30, which is reserved for future use; use a minus sign if it's a negative number.

Enter the cents portion of the difference amount for line 30, which is reserved for future use.

Enter the dollar amount for the total corrected amount in Column 1, reserved for future use on line 31a.

Enter the cents amount for the total corrected amount in Column 1, reserved for future use on line 31a.

Enter the dollar amount for the amount originally reported or previously corrected in Column 2, reserved for future use on line 31a.

Enter the cents amount for the amount originally reported or previously corrected in Column 2, reserved for future use on line 31a.

Enter the dollar amount for the difference in Column 3, reserved for future use on line 31a.

Enter the cents amount for the difference in Column 3, reserved for future use on line 31a.

This box is reserved for future use and currently has no defined function on the form.

Enter the first component of the value for the field reserved for future use on line 32.

Enter the second component of the value for the field reserved for future use on line 32.

Enter the third component of the value for the field reserved for future use on line 32.

Enter the fourth component of the value for the field reserved for future use on line 32.

Enter the fifth component of the value for the field reserved for future use on line 32.

Enter the sixth component of the value for the field reserved for future use on line 32.

Enter the total corrected dollar amount for wages, tips, and other compensation for all employees.

Enter the total corrected cents amount for wages, tips, and other compensation for all employees.

Enter the dollar amount originally reported or previously corrected for wages, tips, and other compensation for all employees.

Enter the cents amount originally reported or previously corrected for wages, tips, and other compensation for all employees.

Enter the dollar difference between the corrected amount and the originally reported amount for wages, tips, and other compensation.

Enter the cents difference between the corrected amount and the originally reported amount for wages, tips, and other compensation.

Provide the total corrected dollar amount of federal income tax withheld from all employees' compensation.

Provide the cents part of the total corrected amount of federal income tax withheld from all employees' compensation.

Provide the dollar amount of federal income tax withheld from all employees' compensation as originally reported or previously corrected.

Provide the cents part of the federal income tax withheld from all employees' compensation as originally reported or previously corrected.

Provide the dollar amount representing the difference in federal income tax withheld.

Provide the cents part representing the difference in federal income tax withheld.

Enter the dollar amount for the federal income tax correction, which should be copied from Column 3.

Enter the cents part for the federal income tax correction, which should be copied from Column 3.

Enter the total corrected taxable social security wages for all employees, representing the whole dollar amount.

Enter the total corrected taxable social security wages for all employees, representing the cents portion.

Enter the amount of taxable social security wages originally reported or previously corrected for all employees, representing the whole dollar amount.

Enter the amount of taxable social security wages originally reported or previously corrected for all employees, representing the cents portion.

Enter the difference between the total corrected and the originally reported taxable social security wages, representing the whole dollar amount. Use a minus sign if the amount is negative.

Enter the difference between the total corrected and the originally reported taxable social security wages, representing the cents portion. Use a minus sign if the amount is negative.

Enter the tax correction amount for taxable social security wages, which is calculated by multiplying the difference in Column 3 by 0.124, representing the whole dollar amount.

Enter the tax correction amount for taxable social security wages, which is calculated by multiplying the difference in Column 3 by 0.124, representing the cents portion.

Enter the dollar amount of the total corrected qualified sick leave wages for all employees.

Enter the cents amount of the total corrected qualified sick leave wages for all employees.

Enter the dollar amount of qualified sick leave wages originally reported or previously corrected for all employees.

Enter the cents amount of qualified sick leave wages originally reported or previously corrected for all employees.

Enter the dollar amount of the difference between the total corrected and originally reported qualified sick leave wages.

Enter the cents amount of the difference between the total corrected and originally reported qualified sick leave wages.

Enter the dollar amount of the tax correction for qualified sick leave wages.

Enter the cents amount of the tax correction for qualified sick leave wages.

Provide the legal name of the employer, not including any trade name.

Please enter the legal name of the entity, not its trade name.

Please enter the name of the entity, excluding its trade name.

Provide the official name of the entity, not its trade name.

Enter the street address for the paid preparer.

Enter the city for the paid preparer's address.

Enter the state for the paid preparer's address.

Enter the ZIP code for the paid preparer's address.

Check this box if the individual preparing this form for compensation is self-employed.

Enter the full name of the paid preparer.

Enter the Preparer Tax Identification Number (PTIN) for the paid preparer.

Enter the name of the preparer's firm, or your name if self-employed. Fill only if 'Self-Employed Preparer' is 'Yes'.

Enter the Employer Identification Number (EIN) for the preparer's firm. Fill only if 'Self-Employed Preparer' is 'No'.

Enter the preparer's daytime phone number, including the area code.

Check this box if you certify that you have filed or will file Forms W-2, Wage and Tax Statement, or Forms W-2c, Corrected Wage and Tax Statement, as required.

Check this box if you are correcting both underreported and overreported tax amounts, or only underreported, and want to use the adjustment process.

Check this box if you overreported tax amounts only and want to use the claim process to request a refund or abatement.

Check this box if the quarter you are correcting spans the months of January, February, or March.

Check this box if the quarter you are correcting spans the months of April, May, or June.

Check this box if the quarter you are correcting spans the months of July, August, or September.

Check this box if the quarter you are correcting spans the months of October, November, or December.

Check this box if you are correcting a Form 941.

Check this box if you are correcting a Form 941-SS.

Enter the whole dollar portion of the total corrected amount for all employees for line 33a.

Enter the cents portion of the total corrected amount for all employees for line 33a.

Enter the whole dollar portion of the amount originally reported or previously corrected for all employees for line 33a.

Enter the cents portion of the amount originally reported or previously corrected for all employees for line 33a.

Enter the whole dollar portion of the difference for line 33a. If the amount is negative, include a minus sign.

Enter the cents portion of the difference for line 33a.

Enter the dollar amount for the total corrected amount for all employees for row 33b.

Enter the cents portion of the total corrected amount for all employees for row 33b.

Enter the dollar amount originally reported or previously corrected for all employees for row 33b.

Enter the cents portion of the amount originally reported or previously corrected for all employees for row 33b.

Enter the dollar amount of the difference for row 33b, using a minus sign if it's a negative number.

Enter the cents portion of the difference amount for row 33b.

Enter the dollar amount for Column 1 of line 34, which is currently reserved for future use.

Enter the cents amount for Column 1 of line 34, which is currently reserved for future use.

Enter the dollar amount for Column 2 of line 34, which is currently reserved for future use.

Enter the cents amount for Column 2 of line 34, which is currently reserved for future use.

Enter the dollar amount for Column 3 of line 34, which is currently reserved for future use. Use a minus sign if the amount is negative.

Enter the cents amount for Column 3 of line 34, which is currently reserved for future use.

Enter the total corrected dollar amount for qualified sick leave wages for leave taken after March 31, 2021, and before October 1, 2021. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the total corrected cents amount for qualified sick leave wages for leave taken after March 31, 2021, and before October 1, 2021. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the dollar amount originally reported or previously corrected for qualified sick leave wages for leave taken after March 31, 2021, and before October 1, 2021. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the cents amount originally reported or previously corrected for qualified sick leave wages for leave taken after March 31, 2021, and before October 1, 2021. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the dollar portion of the difference for qualified sick leave wages. If the amount is negative, include a minus sign. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the cents portion of the difference for qualified sick leave wages. If the amount is negative, include a minus sign. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the total corrected dollar amount of qualified health plan expenses allocable to qualified sick leave wages for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the total corrected cents amount of qualified health plan expenses allocable to qualified sick leave wages for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the dollar amount of qualified health plan expenses allocable to qualified sick leave wages that was originally reported or previously corrected for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the cents amount of qualified health plan expenses allocable to qualified sick leave wages that was originally reported or previously corrected for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the dollar amount representing the difference in qualified health plan expenses allocable to qualified sick leave wages. Use a minus sign if it's a negative number. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the cents amount representing the difference in qualified health plan expenses allocable to qualified sick leave wages. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the total corrected dollar amount for collectively bargained sick leave wages for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the total corrected cents amount for collectively bargained sick leave wages for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the dollar amount originally reported or previously corrected for collectively bargained sick leave wages for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the cents amount originally reported or previously corrected for collectively bargained sick leave wages for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the dollar amount representing the difference for collectively bargained sick leave wages. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the cents amount representing the difference for collectively bargained sick leave wages. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the dollar amount of the total corrected qualified family leave wages for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the cents amount of the total corrected qualified family leave wages for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the dollar amount of the qualified family leave wages originally reported or previously corrected for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the cents amount of the qualified family leave wages originally reported or previously corrected for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the dollar amount of the difference in qualified family leave wages. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the cents amount of the difference in qualified family leave wages. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the dollar amount for the total corrected qualified health plan expenses allocable to qualified family leave wages for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the cent amount for the total corrected qualified health plan expenses allocable to qualified family leave wages for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the dollar amount for the qualified health plan expenses allocable to qualified family leave wages that were originally reported or previously corrected for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the cent amount for the qualified health plan expenses allocable to qualified family leave wages that were originally reported or previously corrected for all employees. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the dollar amount representing the difference in qualified health plan expenses allocable to qualified family leave wages, using a minus sign if the result is a negative number. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the cent amount representing the difference in qualified health plan expenses allocable to qualified family leave wages, using a minus sign if the result is a negative number. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the total corrected dollar amount for collectively bargained family leave wages. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the total corrected cent amount for collectively bargained family leave wages. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the dollar amount originally reported or previously corrected for collectively bargained family leave wages. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the cent amount originally reported or previously corrected for collectively bargained family leave wages. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the dollar amount representing the difference for collectively bargained family leave wages. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Enter the cent amount representing the difference for collectively bargained family leave wages. Fill only if 'Correcting Quarter', 'Correcting Calendar Year' is for a quarter beginning after March 31, 2021.

Provide the full name of the individual signing the form.

Provide the official title of the individual signing the form.

Provide the best daytime phone number for the signatory.

Provide the trade name under which the business operates, if applicable.