Part 1: Select ONLY one process.
Part 2: Complete the certifications.
Enter the date you discovered errors:
For Privacy Act and Paperwork Reduction Act Notice, see the instructions.
Cat. No. 17025J
Form 941-X (Rev. 6-2009)
(Rev. June 2009)
OMB No. 1545-0029
Adjusted Employer’s QUARTERLY Federal Tax Return or Claim for Refund
Department of the Treasury — Internal Revenue Service
Use this form to correct errors you made on Form 941 or 941-SS for one quarter only.
Type or print within the boxes. You MUST complete all three pages. Read the
instructions before completing this form. Do not attach this form to Form 941 or 941-SS.
Return You Are 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 are correcting:
Check the type of return you are correcting:
Check the ONE quarter you are correcting:
(MM / DD / YYYY)
Note. If you are correcting underreported amounts only, go to Part 3 on page 2 and skip lines 4 and 5.
Employer identification number
Name (not your trade name)
Trade name (if any)
Suite or room number
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 are correcting both
underreported and overreported amounts on this form. The amount shown on line 18, if
less than 0, may only be applied as a credit to your Form 941, Form 941-SS, Form 944,
or Form 944-SS for the tax period in which you are filing this form.
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 18. Do not
check this box if y