Schedule D (Form 941):
Report of Discrepancies Caused by Acquisitions, Statutory Mergers, or Consolidations
(Rev. June 2011) Department of the Treasury—Internal Revenue Service
                                                                                                                              OMB No. 1545-0029
Employer Identification Number (EIN)           —                                                    Tax Year of Discrepancies (Fill in)

                                                                                                                       Format: YYYY
Name (not your trade name)

Trade name (if any)
                                                                                                    Type of Submission (Check one)
Address
            Number                       Street                           Suite or room number
                                                                                                              Original

            City                                                    State   ZIP code                          Corrected
Phone number

About this schedule
Each  year  the  Internal  Revenue  Service  (IRS)  and  the  Social  Security  Administration  (SSA)  compare  the  totals  on  your  Forms  941, 
Employer’s QUARTERLY Federal Tax Return, with the totals on Forms W-2, Wage and Tax Statement, to verify that:
      • The wages you reported on Forms 941 match those you reported on Forms W-2 (Copy A) so that your 
       employees’ social security earnings records are complete for benefit purposes; and
      • You have paid the appropriate taxes.
Generally, the totals on your Forms W-2 (Copy A) should equal the totals you reported on Forms 941. Use this schedule if discrepancies 
exist between the totals you reported on those forms ONLY as a result of an acquisition, statutory merger, or consolidation.In many cases, 
the information on this schedule should help the IRS resolve discrepancies without contacting you. If you are an eligible employer 
who elects to use the alternate procedure set forth in Rev. Proc. 2004-53, explained in the instructions, you should file this schedule.
Read the separate instructions before you fill out this schedule.

Part 1: Answer these background questions.

1. Are you filing this schedule —
      After a statutory merger or consolidation? (See Rev. Rul. 62-60, 1962-1 C.B. 186 and Rev. Proc. 2004-53, 2004-2 C.B. 320.)
                                                                                              You are either: An acquired corporation or
                                                                                                              A surviving corporation.
                                               OR
      After an acquisition and you are using the alternate procedure under Rev. Proc. 2004-53, 2004-2 C.B. 320?
                                                                                              You are either: A predecessor or
                                                                                                              A successor.

2. The effective date of the statutory merger/consolidation or acquisition is . . . . . . . . .
                                                                                                              MM        /        DD        /        YYYY
3. The OTHER PARTY in this transaction is . . .
Other party’s EIN                     —

Other party’s name

Trade name (if any)

Address
                          Number            Street                                                                    Suite or room number

                          City                                                                State                   ZIP code
Phone number                                                                                                                              Next ■▶
For Paperwork Reduction Act Notice, see separate instructions.              Cat. No. 38791Y                   Schedule D (Form 941) (Rev. 6-2011)

Your EIN                   —                                                                            Tax Year of Discrepancies (Fill in)

Name (not your trade name)                                                                                             Format: YYYY

Other party’s EIN                —

Part 2: Tell us about the discrepancies with your returns.

                                  Column A                                        Column B                             Column C
                                 Amount you reported to IRS         – Amount you reported to SSA          = The difference
                                 for the tax year                     for the tax year
                                 Totals from Forms 941 as corrected   Totals from Forms W-2 (Copy A) as 
                                 by any Forms 941-X                   corrected by any Forms W-2c (Copy A)

4. Social security wages                                            –                                     =
5. Medicare wages and tips                                          –                                     =
6. Social security tips                                             –                                     =
7. Federal income tax                                               –                                     =
   withheld
8. Advance earned income credit                                     –                                     =
   (EIC) payments (for tax years 
   ending before January 1, 2011)

If you are filing for one transaction only, STOP here. If you are filing for more than one transaction, go to Part 3.

Part 3: Fill this part out ONLY if you are filing more than one Schedule D (Form 941) for any calendar year.

9. File one Schedule D (Form 941) for each separate transaction. This is schedule     of                   . (Example: This is schedule 1 of 3.)

                                  Column A                                        Column B                             Column C
                                 Amount you reported to IRS         – Amount you reported to SSA          = The difference
                                 for the tax year for the             for the tax year for the 
                                 employees affected by the            employees affected by the 
                                 transaction reported on this         transaction reported on this 
                                 Schedule D (Form 941)                Schedule D (Form 941)

                                 Totals from Forms 941 as corrected   Totals from Forms W-2 (Copy A) as 
                                 by any Forms 941-X                   corrected by any Forms W-2c (Copy A)

10. Social security wages                                           –                                     =
11. Medicare wages and tips                                         –                                     =
12. Social security tips                                            –                                     =
13. Federal income tax                                              –                                     =
   withheld
14. Advance earned income credit 
   (EIC) payments (for tax years                                    –                                     =
   ending before January 1, 2011)

Page 2                                                                                                       Schedule D (Form 941) (Rev. 6-2011)