Schedule R (Form 940):                     Allocation Schedule for Aggregate Form 940 Filers                                                                                     OMB No. 1545-0028
(Rev. December 2017)                                                                                                                                                                               860517
Department of the Treasury — Internal Revenue Service
                                                                                                                                                    Report for calendar year:
Employer identification number (EIN)                  —                                                                                             (Same as Form 940):

Name as shown on Form 940

Type of filer (check one):         Section 3504 Agent        Certified Professional Employer Organization (CPEO)

Read the instructions before you complete Schedule R (Form 940). Type or print within the boxes. Complete a separate line for the amounts 
allocated to each of your clients. The term “client” as used on this form includes the term “customer.” See the instructions.
              (a)                      (b)                 (c)                   (d)                            (e)                 (f)                     (g)                      (h) 
     Client’s Employer                 State      Type of wages, tips, and Total taxable FUTA       Total adjustments        Credit reduction amount Total FUTA tax         Total FUTA tax deposits 
   Identification Number            abbreviation     other compensation    wages allocated to         to FUTA tax            allocated to the        after adjustments      from Form 940, line 13, 
              (EIN)                 from Form         (CPEO use only)      the listed client EIN    allocated to the         listed client EIN from  allocated to the       plus any payment made 
                                    940, line 1a,                          from Form 940,line 7     listed client EIN from   Form 940, line 11       listed client EIN from with the return allocated 
                                    or Schedule A                                                Form 940, line 9 or line 10                         Form 940,line 12        to the listed client EIN
                                    (Form 940)  
1                                                                                            .                        .                        .                       .                          .
2                                                                                            .                        .                        .                       .                          .
3                                                                                            .                        .                        .                       .                          .
4                                                                                            .                        .                        .                       .                          .
5                                                                                            .                        .                        .                       .                          .
6                                                                                            .                        .                        .                       .                          .
7                                                                                            .                        .                        .                       .                          .
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9                                                                                            .                        .                        .                       .                          .
10                                                                                           .                        .                        .                       .                          .
11                                                                                           .                        .                        .                       .                          .
12                                                                                           .                        .                        .                       .                          .
13                                                                                           .                        .                        .                       .                          .
14                                                                                           .                        .                        .                       .                          .
15                                                                                           .                        .                        .                       .                          .
16 Subtotals for clients. Add all 
   amounts on lines 1 through 15.
                                                                                             .                        .                        .                       .                          .
17 Enter the combined subtotal 
   from line 23 of all Continuation 
   Sheets for Schedule R (Form 
   940).                                                                                     .                        .                        .                       .                          .
18 Enter Form 940 amounts for 
   your employees.
                                                                                             .                        .                        .                       .                          .
19 Totals. Add lines 16, 17, and 
   18. The column totals must 
   match the related lines on the 
   aggregate Form 940.                                                                       .                        .                        .                       .                          .
For Paperwork Reduction Act Notice, see the instructions.                       www.irs.gov/Form940                                 Cat. No. 53082A                Schedule R (Form 940) (Rev. 12-2017)

Page    of
Continuation Sheet for Schedule R (Form 940)
                                                                                                                                                                                                   860617
(Rev. December 2017)

                                                                                                                                                    Report for calendar year:
Employer identification number (EIN)              —                                                                                                 (Same as Form 940):

Name as shown on Form 940

Type of filer (check one):    Section 3504 Agent         Certified Professional Employer Organization (CPEO)

              (a)                      (b)              (c)                      (d)                        (e)                     (f)                     (g)                      (h) 
     Client’s Employer                 State      Type of wages, tips, and Total taxable FUTA    Total adjustments           Credit reduction amount Total FUTA tax         Total FUTA tax deposits 
     Identification Number          abbreviation  other compensation       wages allocated to         to FUTA tax            allocated to the        after adjustments      from Form 940, line 13, 
              (EIN)                 from Form     (CPEO use only)          the listed client EIN allocated to the            listed client EIN from  allocated to the       plus any payment made 
                                    940, line 1a,                          from Form 940,line 7  listed client EIN from      Form 940, line 11       listed client EIN from with the return allocated 
                                    or Schedule A                                                Form 940, line 9 or line 10                         Form 940,line 12        to the listed client EIN
                                    (Form 940)  
1                                                                                            .                       .                         .                       .                          .
2                                                                                            .                       .                         .                       .                          .
3                                                                                            .                       .                         .                       .                          .
4                                                                                            .                       .                         .                       .                          .
5                                                                                            .                       .                         .                       .                          .
6                                                                                            .                       .                         .                       .                          .
7                                                                                            .                       .                         .                       .                          .
8                                                                                            .                       .                         .                       .                          .
9                                                                                            .                       .                         .                       .                          .
10                                                                                           .                       .                         .                       .                          .
11                                                                                           .                       .                         .                       .                          .
12                                                                                           .                       .                         .                       .                          .
13                                                                                           .                       .                         .                       .                          .
14                                                                                           .                       .                         .                       .                          .
15                                                                                           .                       .                         .                       .                          .
16                                                                                           .                       .                         .                       .                          .
17                                                                                           .                       .                         .                       .                          .
18                                                                                           .                       .                         .                       .                          .
19                                                                                           .                       .                         .                       .                          .
20                                                                                           .                       .                         .                       .                          .
21                                                                                           .                       .                         .                       .                          .
22                                                                                           .                       .                         .                       .                          .
23 Subtotals for clients. Add lines 
   1 through 22. Include the 
   subtotals from line 23 on 
   Schedule R (Form 940), line 17.                                                           .                       .                         .                       .                          .
                                                                                                                                                                   Schedule R (Form 940) (Rev. 12-2017)

                                                                                                                                        860717
Schedule R (Form 940) (Rev. 12-2017)
Section references are to the Internal Revenue Code unless otherwise        Column a. Your client’s EIN. 
noted.                                                                      Column b. The state abbreviation of the client’s location. 
Future Developments                                                         Column c (CPEO Use Only). Type of wages, tips, and other 
                                                                            compensation. Enter a code to report the type of wages, tips, and other 
For the latest information about developments related to Schedule R and     compensation paid to the individual(s) performing services for the client. 
its instructions, such as legislation enacted after they were published, go If you paid more than one type of wages, tips, or other compensation, 
to www.irs.gov/Form940.                                                     you must use more than one line to report for that client and enter the 
                                                                            applicable code for each line. The following four codes are the only 
What’s New                                                                  entries that can be made in column c. 
A certified professional employer organization (CPEO) must attach           • A: Wages, tips, and other compensation paid under section 3511(a).
Schedule R to its aggregate Form 940, Employer’s Annual Federal             • B: Wages, tips, and other compensation paid under section 3511(c).
Unemployment (FUTA) Tax Return.
                                                                            • C: Wages, tips, and other compensation not reported under Code A 
                                                                                or Code B paid as a payor under a service agreement described in 
General Instructions                                                            Regulations section 31.3504-2(b)(2).
Purpose of Schedule R                                                       • D: Wages, tips, and other compensation paid as an agent under 
                                                                                Regulations section 31.3504-1.
Use Schedule R to allocate the aggregate information reported on Form       Column d. Total taxable FUTA wages allocated to the listed client EIN 
940 to each client. For purposes of Schedule R, the term “client” means     from Form 940, line 7.
(a) a home care service recipient identified on the Form 2678, Employer/
Payer Appointment of Agent; (b) a customer who enters into a contract       Column e. Total adjustments to FUTA tax allocated to the listed client 
that meets the requirements under section 7705(e)(2); or (c) a client who   EIN from Form 940, line 9 or 10. 
enters into a service agreement described under Regulations section         Column f. Credit reduction amount allocated to the listed client EIN from 
31.3504-2(b)(2) with a CPEO. If you have more than 15 clients, complete     Form 940, line 11. 
as many continuation sheets as necessary. Attach Schedule R, including 
any continuation sheets, to your aggregate Form 940.                        Column g. Total FUTA tax after adjustments allocated to the listed client 
                                                                            EIN from Form 940, line 12. 
Who Must File?                                                              Column h. Total FUTA tax deposits from Form 940, line 13, plus any 
You must complete Schedule R if you file an aggregate Form 940.             other payments allocated to the listed client EIN. 
Aggregate Forms 940 are filed by agents of home care service recipients     You must also report the same information for your employees on 
approved by the IRS under section 3504 and by CPEOs. To request             Schedule R, line 18.
approval to act as an agent for a home care service recipient, you must     Compare the total of each column on Schedule R, line 19 (including 
file Form 2678 with the IRS, unless you are a state or local government     your information from Schedule R, line 18) to the amounts reported on 
agency acting as agent under the special procedures provided in Rev.        the aggregate Form 940. For each column total, the relevant line from 
Proc. 2013-39. Form 2678 must be previously filed and approved by the       Form 940 is noted in the column heading.
IRS before filing Schedule R. To become a CPEO, you must apply 
through the IRS Online Registration System. Visit www.irs.gov/CPEO for      If the totals on Schedule R, line 19, don’t match the totals on Form 
more information.                                                           940, there is an error that must be corrected before submitting Form 940 
                                                                            and Schedule R.
When Must You File?
                                                                            Paperwork Reduction Act Notice. We ask for the information on 
If you’re an aggregate Form 940 filer, file Schedule R with your            Schedule R to carry out the Internal Revenue laws of the United States. 
aggregate Form 940 every year when your Form 940 is due. Agents may         You are required to give us this information. We need it to ensure that 
file Form 940 and Schedule R electronically or by paper submission.         you are complying with these laws and to allow us to figure and collect 
CPEOs generally must file Form 940 and Schedule R electronically. For       the right amount of tax.
more information about a CPEO’s requirement to file electronically, see 
Rev. Proc. 2017-14, 2017-3 I.R.B. 426, available at                         You’re not required to provide the information requested on a form 
www.irs.gov/irb/2017-03_IRB/ar14.html.                                      that is subject to the Paperwork Reduction Act unless the form displays 
                                                                            a valid OMB control number. Books or records relating to a form or its 
                                                                            instructions must be retained as long as their contents may become 
Specific Instructions                                                       material in the administration of any Internal Revenue law. Generally, tax 
                                                                            returns and return information are confidential, as required by section 
Completing Schedule R                                                       6103.
Enter Your Business Information                                             The time needed to complete and file Schedule R will vary depending 
                                                                            on individual circumstances. The estimated average time is:
Carefully enter your employer identification number (EIN) and the name 
of your business at the top of the schedule. Make sure they exactly         Recordkeeping      . .   .  .    . .  .  .    .  . .  .     . . . 11 hr.
match the EIN and name shown on the attached Form 940. Check one            Learning about the law or the form  .    .    .  . .  .     . .    18 min.
of the “Type of filer” boxes to tell us if you’re a section 3504 agent or a Preparing, copying, and assembling the form      . .  .     . .  29 min.
CPEO.
                                                                            If you have comments concerning the accuracy of these time 
Calendar Year                                                               estimates or suggestions for making Schedule R simpler, we would be 
                                                                            happy to hear from you. You can send us comments from     
Enter the calendar year for which you are filing your Form 940. Make        www.irs.gov/FormComments. Or you can send your comments to 
sure that the year entered on the top of Schedule R matches the year on     Internal Revenue Service, Tax Forms and Publications Division, 1111 
the attached Form 940.                                                      Constitution Ave., NW, IR-6526, Washington, DC 20224. Don’t send 
Client and Employee Information                                             Schedule R to this address. Instead, see Where Do You File? in the 
                                                                            Instructions for Form 940.
On Schedule R, including any continuation sheets, you must report the 
following for each client.
Note: When entering amounts over 999.99 on Schedule R, don’t enter 
commas.