Form   945-X:        Adjusted Annual Return of Withheld Federal Income Tax or Claim for Refund
(Rev. February 2012)           Department of the Treasury — Internal Revenue Service                                                                             OMB No. 1545-1430
Employer identification number          —                                                                                                    Return You Are Correcting ...
(EIN)
                                                                                                                                             Enter the calendar year of the return  
Name (not your trade name)                                                                                                                   you are correcting: 
                                                                                                                                                        (YYYY) 
Trade name (if any)

Address                                                                                                                                      Enter the date you discovered errors:
           Number                    Street                                                                            Suite or room number

           City                                             State             ZIP code                                                       (MM / DD / YYYY) 

Use this form to correct administrative errors made on Form 945, Annual Return of Withheld Federal Income Tax. Use a separate 
Form 945-X for each year that needs correction. Please type or print within the boxes. Do not attach this form to Form 945. 
You MUST complete both pages. Read the separate instructions before you complete this form. 
Part 1:    Select ONLY one process. 

       1. Adjusted return of withheld federal income tax. 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 5, if less than zero, may only be applied as a credit to 
          your Form 945 for the tax period in which you are 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 5. Do not check this box if you are correcting ANY underreported amounts on this form. 

Part 2:   Enter the corrections for the calendar year you are correcting. If any line does not apply, leave it blank. 

                                          Column 1                   Column 2                                                                Column 3 
                                                               Amount originally           Difference   
                                        Total corrected     —  reported or as            = (If this amount is a  
                                        amount                 previously corrected        negative number,  
                                        (for ALL payees)       (for ALL payees)            use a minus sign.) 

       3. Federal income tax withheld 
          (from line 1 of Form 945)  .                    .    —                       .                                                   =          . 

       4. Backup withholding   
          (from line 2 of Form 945)  .                    .    —                       .                                                   =          . 

       5.  Total. Combine the amounts in lines 3 and 4 of Column 3 . .        . . .    . . .                                                          . 
          If line 5 is less than zero: 
          • If you checked line 1, this is the amount you want applied as a credit to your Form 945 for the tax period in which you are   
             filing this form. 
          • If you checked line 2, this is the amount you want refunded or abated. 
          If line 5 is more than zero, this is the amount you owe. Pay this amount when you file this return. For information on how to 
          pay,  seeAmount You Owe in the instructions for line 5. 
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For Paperwork Reduction Act Notice, see the separate instructions.                       Cat. No. 20336X                                                Form 945-X (Rev. 2-2012) 

Name (not your trade name)                                                 Employer identification number (EIN) Calendar Year (YYYY) 

Part 3: Explain your corrections for the calendar year you are correcting. 

     6. Check here if any corrections you entered on a line include both underreported and overreported amounts.  
        Explain both your underreported and overreported amounts on line 7. 

     7. You must give us a detailed explanation of how you determined your corrections. See the separate instructions. 

Part 4: Sign here. You must complete both pages of this form and sign it. 
Under penalties of perjury, I declare that I have filed an original Form 945 and that I have examined this adjusted return or claim and any schedules or  
statements that are attached, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than 
taxpayer) is based on all information of which preparer has any knowledge. 
                                                                            Print your 
                                                                            name here
        Sign your 
✗       name here                                                           Print your 
                                                                            title here

                Date                                                        Best daytime phone

Paid Preparer Use Only                                                     Check if you are self-employed       . . . .      . .     . .

Preparer’s name                                                                       PTIN 

Preparer’s signature                                                                  Date 
Firm’s name (or yours if  
self-employed)                                                                        EIN 

Address                                                                               Phone 

City                       State                                                      ZIP code 
Page 2                                                                                                              Form 945-X (Rev. 2-2012)