Form 941-SS for 2022:                        Employer’s QUARTERLY Federal Tax Return
(Rev. June 2022)                                        American Samoa, Guam, the Commonwealth of the Northern 
Department of the Treasury — Internal Revenue Service         Mariana Islands, and the U.S. Virgin Islands                                                                                   OMB No. 1545-0029
                                             —                                                                                                                          Report for this Quarter of 2022 
Employer identification number (EIN)                                                                                                                                    (Check one.)
Name (not your trade name)                                                                                                                                                1: January, February, March
                                                                                                                                                                          2: April, May, June
Trade name (if any)
                                                                                                                                                                          3: July, August, September
Address                                                                                                                                                                   4: October, November, December
        Number              Street                                                                                                             Suite or room number     Go to www.irs.gov/Form941SS for  
                                                                                                                                                                        instructions and the latest information.
        City                                                       State                    ZIP code

        Foreign country name                              Foreign province/county   Foreign postal code
Read the separate instructions before you complete Form 941-SS. Type or print within the boxes.
Part 1: Answer these questions for this quarter.
1    Number of employees who received wages, tips, or other compensation for the pay period 
     including: June 12 (Quarter 2), Sept. 12 (Quarter 3), or Dec. 12 (Quarter 4) .                 .  .                                                            . . . .   1
2
3
4    If no wages, tips, and other compensation are subject to social security or Medicare tax                                                                                         Check and go to line 6.
                                                        Column 1                                    Column 2
5a   Taxable social security wages*                              .                × 0.124 =                                                                             .         *Include taxable qualified sick and 
                                                                                                                                                                                  family leave wages paid in this 
                                                                                                                                                                                  quarter of 2022 for leave taken 
                                                                                                                                                                                  after March 31, 2021, and before 
5a   (i) Qualified sick leave wages*                             .                × 0.062 =                                                                             .         October 1, 2021, on line 5a. Use 
                                                                                                                                                                                  lines 5a(i) and 5a(ii) only for 
5a   (ii) Qualified family leave wages*                          .                × 0.062 =                                                                             .         taxable qualified sick and family 
                                                                                                                                                                                  leave wages paid in this quarter of 
                                                                                                                                                                                  2022 for leave taken after March 
5b   Taxable social security tips                                .                × 0.124 =                                                                             .         31, 2020, and before April 1, 2021.
5c   Taxable Medicare wages & tips                               .                × 0.029 =                                                                             .
5 d  Taxable wages & tips subject to 
     Additional Medicare Tax withholding                         .                × 0.009 =                                                                             .
5e   Total social security and Medicare taxes. Add column 2 from lines 5a, 5a(i), 5a(ii), 5b, 5c, and 5d .                                                                    5e                                  .
5f   Section 3121(q) Notice and Demand—Tax due on unreported tips (see instructions)                                                                                  . . .   5f                                  .
6    Total taxes before adjustments. Add lines 5e and 5f .         . .            . . .     . .     .  .                                                            . . . .   6                                   .
7    Current quarter’s adjustment for fractions of cents         . . .            . . .     . .     .  .                                                            . . . .   7                                   .
8    Current quarter’s adjustment for sick pay            . . .  . . .            . . .     . .     .  .                                                            . . . .   8                                   .
9    Current quarter’s adjustments for tips and group-term life insurance                   . .     .  .                                                            . . . .   9                                   .
10   Total taxes after adjustments. Combine lines 6 through 9        .            . . .     . .     .  .                                                            . . . .   10                                  .
11a  Qualified small business payroll tax credit for increasing research activities. Attach Form 8974                                                                     .   11a                                 .
11 b Nonrefundable portion of credit for qualified sick and family leave wages for leave taken before 
     April 1, 2021 . .         .     . . . . .        . . . . .  . . .            . . .     . .     .  .                                                            . . . .   11b                                 .
11c  Reserved for future use           . . . .        . . . . .  . . .            . . .     . .     .  .                                                            . . . .   11c                                 .

     ▶ You MUST complete all three pages of Form 941-SS and SIGN it.                                                                                                                                         Next ■▶
For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher.                                                                              Cat. No. 17016Y Form 941-SS (Rev. 6-2022)

Name (not your trade name)                                                                   Employer identification number (EIN)
                                                                                                      –
Part 1:   Answer these questions for this quarter. (continued)
11 d  Nonrefundable  portion  of  credit  for  qualified  sick  and  family  leave  wages  for  leave  taken 
       after March 31, 2021, and before October 1, 2021      .             . . . . . . . . . .    . . .      11d                           .

11e    Reserved for future use   .  .     . . . .      . . . .             . . . . . . . . . .    . . .      11e                           .
11f    Reserved for future use   .  .     . . . .      . . . .             . . . 

11g    Total nonrefundable credits. Add lines 11a, 11b, and 11d              . . . . . . . . .    . . .      11g                           .

12     Total taxes after adjustments and nonrefundable credits. Subtract line 11g from line 10      . .      12                            .
13 a  Total deposits for this quarter, including overpayment applied from a prior quarter and 
       overpayments applied from Form 941-X, 944-X, or 944-X (SP) filed in the current quarter        .   13a                              .

13b    Reserved for future use   .  .     . . . .      . . . .             . . . . . . . . . .    . . .      13b                           .
13 c  Refundable portion of credit for qualified sick and family leave wages for leave taken before 
       April 1, 2021 .     . . . .  .     . . . .      . . . .             . . . . . . . . . .    . . .      13c                           .

13d    Reserved for future use   .  .     . . . .      . . . .             . . . . . . . . . .    . . .      13d                           .
13 e  Refundable portion of credit for qualified sick and family leave wages for leave taken after 
       March 31, 2021, and before October 1, 2021        . . .             . . . . . . . . . .    . . .      13e                           .

13f    Reserved for future use   .  .     . . . .      . . . .             . . . . . . . . . .    . . .      13f                           .

13g    Total deposits and refundable credits. Add lines 13a, 13c, and 13e          . . . . . .    . . .      13g                           .

13h    Reserved for future use   .  .     . . . .      . . . .             . . . . . . . . . .    . . .      13h                           .

13i    Reserved for future use   .  .     . . . .      . . . .             . . . . . . . . . .    . . .      13i                           .

14     Balance due. If line 12 is more than line 13g, enter the difference and see instructions . . . .      14                            .

15     Overpayment. If line 13g is more than line 12, enter the difference             .   Check one:   Apply to next return.    Send a refund.
Part 2:   Tell us about your deposit schedule and tax liability for this quarter.
If you’re unsure about whether you’re a monthly schedule depositor or a semiweekly schedule depositor, see section 8 of Pub. 80. 
16     Check one:          Line 12 on this return is less than $2,500 or line 12 on the return for the prior quarter was less than $2,500, 
                           and you didn’t incur a $100,000 next-day deposit obligation during the current quarter. If line 12 for the prior 
                           quarter was less than $2,500 but line 12 on this return is $100,000 or more, you must provide a record of your 
                           federal tax liability. If you’re a monthly schedule depositor, complete the deposit schedule below; if you’re a 
                           semiweekly schedule depositor, attach Schedule B (Form 941). Go to Part 3.

                           You were a monthly schedule depositor for the entire quarter. Enter your tax liability for each month and total 
                           liability for the quarter, then go to Part 3.

                           Tax liability:   Month 1                                  .
                                            Month 2                                  .
                                            Month 3                                  .

                           Total liability for quarter                               .     Total must equal line 12.
                           You were a semiweekly schedule depositor for any part of this quarter.Complete Schedule B (Form 941), 
                           Report of Tax Liability for Semiweekly Schedule Depositors, and attach it to Form 941-SS. Go to Part 3.

       ▶  You MUST complete all three pages of Form 941-SS and SIGN it.                                                           Next ■▶
Page 2                                                                                                              Form 941-SS (Rev. 6-2022)

Name (not your trade name)                                                       Employer identification number (EIN)
                                                                                                       –
Part 3: Tell us about your business. If a question does NOT apply to your business, leave it blank.
17     If your business has closed or you stopped paying wages . . . .   . . . . . .     .             .             . . . .         Check here, and
       enter the final date you paid wages     /       /                 ; also attach a statement to your return. See instructions.

18     If you’re a seasonal employer and you don’t have to file a return for every quarter of the year               . . . .         Check here.

19     Qualified health plan expenses allocable to qualified sick leave wages for leave taken before April 1, 2021   19                                  .
20     Qualified health plan expenses allocable to qualified family leave wages for leave taken before April 1, 2021 20                                  .
21     Reserved for future use   . . .     . . . . . . . .     . . . .   . . . . . .     .             .             21                                  .
22     Reserved for future use   . . .     . . . . . . . .     . . . .   . . . . . .     .             .             22                                  .
23     Qualified sick leave wages for leave taken after March 31, 2021, and before October 1, 2021                   23                                  .
24     Qualified health plan expenses allocable to qualified sick leave wages reported on line 23      .             24                                  .
25     Amounts under certain collectively bargained agreements allocable to qualified sick leave 
       wages reported on line 23   . .     . . . . . . . .     . . . .   . . . . . .     .             .             25                                  .

26     Qualified family leave wages for leave taken after March 31, 2021, and before October 1, 2021                 26                                  .
27     Qualified health plan expenses allocable to qualified family leave wages reported on line 26    .             27                                  .
28     Amounts under certain collectively bargained agreements allocable to qualified family leave 
       wages reported on line 26   . .     . . . . . . . .     . . . .   . . . . . .     .             .             28                                  .
Part 4: May we speak with your third-party designee?
        Do you want to allow an employee, a paid tax preparer, or another person to discuss this return with the IRS? See the 
        instructions for details.

        Yes.      Designee’s name and phone number

                  Select a 5-digit personal identification number (PIN) to use when talking to the IRS.
        No.

Part 5: Sign here. You MUST complete all three pages of Form 941-SS and SIGN it.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and 
belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

                                                                               Print your 
        Sign your                                                              name here
        name here
                                                                               Print your 
✗                                                                              title here
                      Date         /        /
                                                                               Best daytime phone

Paid Preparer Use Only                                                           Check if you’re 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 3                                                                                                                     Form 941-SS (Rev. 6-2022)

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Form 941-V(SS), 
Payment Voucher

Purpose of Form                                                             Specific Instructions
Complete Form 941-V(SS) if you’re making a payment                          Box 1—Employer identification number (EIN). If you 
with Form 941-SS. We will use the completed voucher to                      don’t have an EIN, you may apply for one online by 
credit your payment more promptly and accurately, and                       visiting the IRS website at www.irs.gov/EIN. You may also 
to improve our service to you.                                              apply for an EIN by faxing or mailing Form SS-4 to the 
                                                                            IRS. If you haven’t received your EIN by the due date of 
Making Payments With Form 941-SS                                            Form 941-SS, write “Applied For” and the date you 
To avoid a penalty, make your payment with Form                             applied in this entry space.
941-SS only if:                                                             Box 2—Amount paid. Enter the amount paid with 
• Your total taxes after adjustments and nonrefundable                      Form 941-SS.
credits (Form 941-SS, line 12) for either the current                       Box 3—Tax period. Darken the circle identifying the 
quarter or the preceding quarter are less than $2,500, you                  quarter for which the payment is made. Darken only 
didn’t incur a $100,000 next-day deposit obligation during                  one circle.
the current quarter, and you’re paying in full with a timely 
filed return; or                                                            Box 4—Name and address. Enter your name and 
                                                                            address as shown on Form 941-SS.
• You’re a monthly schedule depositor making a payment 
in accordance with the Accuracy of Deposits Rule. See                       • Enclose your check or money order made payable to    
section 8 of Pub. 80 for details. In this case, the amount                  “United States Treasury.” Be sure to enter your EIN, 
of your payment may be $2,500 or more.                                      “Form 941-SS,” and the tax period (“1st Quarter 2022,” 
                                                                            “2nd Quarter 2022,” “3rd Quarter 2022,” or “4th Quarter 
     Otherwise, you must make deposits by electronic funds                  2022”) on your check or money order. Don’t send cash. 
transfer. See section 8 of Pub. 80 for deposit instructions.                Don’t staple Form 941-V(SS) or your payment to Form 
Don’t use Form 941-V(SS) to make federal tax deposits.                      941-SS (or to each other).
       Use Form 941-V(SS) when making any                                   • Detach Form 941-V(SS) and send it with your payment 
       payment with Form 941-SS. However, if you pay                        and Form 941-SS to the address in the Instructions for 
▲!     an amount with Form 941-SS that should’ve                            Form 941-SS.
CAUTION
       been deposited, you may be subject to a 
penalty. See Deposit Penalties in section 8 of Pub. 80.                     Note: You must also complete the entity information 
                                                                            above Part 1 on Form 941-SS.

                                                                                                                                      ✃
✁                                          Detach Here and Mail With Your Payment and Form 941-SS.  ▼
                           ▼

                                                                                                                                   OMB No. 1545-0029
                                                         Payment Voucher
Form 941-V(SS)
Department of the Treasury                         ▶   Don’t staple this voucher or your payment to Form 941-SS.
Internal Revenue Service                                                                                                           2022
1    Enter your employer identification                2                                                                   Dollars   Cents
     number (EIN).
                                                         Enter the amount of your payment. ▶
       –                                                 Make your check or money order payable to “United States Treasury”
3    Tax Period                                        4 Enter your business name (individual name if sole proprietor).
       1st                                 3rd 
       Quarter                             Quarter       Enter your address.

       2nd                                 4th           Enter your city, state, and ZIP code; or your city, foreign country name, foreign province/county, and foreign postal code.
       Quarter                             Quarter

Form 941-SS (Rev. 6-2022)

Privacy Act and Paperwork Reduction Act Notice.            Justice for civil and criminal litigation, and to cities, 
We ask for the information on Form 941-SS to carry out     states, the District of Columbia, and U.S. commonwealths 
the Internal Revenue laws of the United States. We         and possessions for use in administering their tax laws. 
need it to figure and collect the right amount of tax.     We may also disclose this information to other countries 
Subtitle C, Employment Taxes, of the Internal Revenue      under a tax treaty, to federal and state agencies to 
Code imposes employment taxes on wages and provides        enforce federal nontax criminal laws, or to federal law 
for income tax withholding. Form 941-SS is used to         enforcement and intelligence agencies to combat 
determine the amount of the taxes that you owe. Section    terrorism.
6011 requires you to provide the requested information if  The time needed to complete and file Form 941-SS 
the tax is applicable to you. Section 6109 requires you to will vary depending on individual circumstances. The 
provide your identification number. If you fail to provide estimated average time is:
this information in a timely manner or provide false or 
fraudulent information, you may be subject to penalties.   Recordkeeping  . . . . . . . . . .  17 hr., 42 min.
You’re not required to provide the information             Learning about the law or the form  . . . .  24 min.
requested on a form that is subject to the Paperwork       Preparing, copying, assembling, and 
Reduction Act unless the form displays a valid OMB         sending the form to the IRS   . . . . . . .  42 min.
control number. Books and records relating to a form or 
                                                           If you have comments concerning the accuracy of 
its instructions must be retained as long as their 
                                                           these time estimates or suggestions for making Form 
contents may become material in the administration of 
                                                           941-SS simpler, we would be happy to hear from you. 
any Internal Revenue law.
                                                           You can send us comments from www.irs.gov/
Generally, tax returns and return information are          FormComments. Or you can send your comments to 
confidential, as required by section 6103. However,        Internal Revenue Service, Tax Forms and Publications 
section 6103 allows or requires the IRS to disclose or     Division, 1111 Constitution Ave. NW, IR-6526, 
give the information shown on your tax return to others    Washington, DC 20224. Don’t send Form 941-SS to this 
as described in the Code. For example, we may              address. Instead, see Where Should You File? in the 
disclose your tax information to the Department of         Instructions for Form 941-SS.