Supporting Statement To Correct Information                                                        OMB No. 1545-0256
 Form    941c
(Rev. October 2006)                                             Do Not File Separately                                                 
Department of the Treasury                                                                                                            Page
Internal Revenue Service       ' File with Forms 941, 941-M, 941-SS, 943, 944, 944(SP), 944-SS, 945, or Form 843.                     No.
 Name                                                                                               Employer identification number     (EIN)
                                                                                                     
Telephone number (optional)                                       A  This form supports adjustments to Form:         Check only one box. (see instructions)
                                                                           941                                        941-SS
                                                                                            941-M                                             943
                                                                           944              944(SP)                   944-SS                  945
 B   This form is attached to and filed with the return for the   C  Enter the date that you discovered the error(s) reported on this form.
     period ending (month, year) '                                   (If you are making more than one correction and the errors were not'
                                                                     discovered at the same time, explain in Part V.)
 Part I          Signature and     Certification     (Youmust complete this part for the IRS to process your adjustments                            for
                 overpayments.) Skip Part I if all of your adjustments are underpayments. (Part I applies to wages only.)
I certify that Forms W-2c, Corrected Wage and Tax Statement, have been filed (as necessary) with                     the Social Security
Administration, and that (check appropriate boxes):
         All overcollected federal income taxes for the current calendar year and all social security and Medicare taxes for the
         current and prior calendar years have been repaid to employees. For claims of overcollected employee social security and
         Medicare taxes in earlier years, a written statement has been obtained from each employee stating that the employee has
         not claimed and will not claim refund or credit for the amount of the overcollection.
          
         All affected employees have given their written consent to the allowance of this credit or refund. For claims of
         overcollected employee social security and Medicare taxes in earlier years, a written statement has been obtained from
         each employee stating that the employee has not claimed and will not claim refund or credit for the amount of the
         overcollection.
          
         The social security tax and Medicare tax adjustments represent the employer’s share only. An attempt was made to
         locate the employee(s) affected, but the affected employee(s) could not be located or will not comply with the certification
         requirements.
          
         None of this refund or credit was withheld from employee wages.
          
Sign
Here             Signature '                                      Title '                                                 Date '
                                                                                                                                
 Part II         Federal Income Tax Withholding (Including Backup Withholding) Adjustment
                  
                                             (a)                                                (b)                      (c)                   (d)
                               Period Corrected (For quarterly                         Withheld Income Tax    Correct Withheld             Withheld Income
                               returns, enter date quarter ended.                      Previously Reported           Income Tax for        Tax Adjustment
                               For annual returns, enter year.)                            for Period                 Period                
                                                                                                                       
 1
   2
   3
   4
   5     Net withheld income tax adjustment. If more than one page, enter total of all columns (d) on first
         page only. Enter here and on the appropriate line of the return with which you file this form.                  '      5
 Part III        Social Security Tax Adjustment        (Use the tax rate in effect during the period(s) corrected.                     You must also
                 complete Part IV.)
                           (a)                        (b)                   (c)                 (d)                      (e)                   (f)
          Period Corrected (For quarterly         Wages Previously   Correct Wages for     Tips Previously           Correct Tips for   Social Security Tax
          returns, enter date quarter ended.     Reported for Period       Period      Reported for Period            Period                Adjustment
          For annual returns, enter year.)                                                                                                   
           
 1
   2
   3
   4
   5     Totals. If more than one page,
         enter totals on first page only     '
 6       Net social security tax adjustment.      If more than one page, enter total of    allcolumns (f) on first
         page only. Enter here and on the appropriate line of the return with which you file this form                   '      6
 7       Net wage adjustment.      If more than one page, enter total of    alllines 7 on first page only. If line 5(c)          
         is smaller than line 5(b), enter difference in parentheses                                                      '      7
 8       Net tip adjustment.    If more than one page, enter total of     all lines 8 on first page only. If line 5(e)           
         is smaller than line 5(d), enter difference in parentheses                                                      '      8
For Paperwork Reduction Act Notice, see page 4.                                   Cat. No. 11242O                            Form      941c   (Rev. 10-2006)
                                                                                                                                               

Form 941c (Rev. 10-2006)                                                                                                    Page 2
                                                                                                                                  
 Part IV Medicare Tax Adjustment
          
                                  (a)                                                 (b)              (c)               (d)
                         Period Corrected (For quarterly                        Wages and Tips   Correct Wages     Medicare Tax
                         returns, enter date quarter ended.                  Previously Reported     and Tips for  Adjustment
                         For annual returns, enter year.)                       for Period            Period        
                                                                                                       
 1
   2
   3
   4
  
 5   Totals. If more than one page, enter totals on first page only  '
   6 Net Medicare tax adjustment. If more than one page, enter total of      allcolumns (d) on first page
     only. Enter here and on the appropriate line of the return with which you file this form          '          6
 7   Net wage and tip adjustment. If more than one page, enter total of      alllines 7 on first page only.        
     If line 5(c) is smaller than line 5(b), enter difference in parentheses                           '          7
                                                                                                                   
 Part V  Explanation of Adjustments
          
                                                                                                             Form  941c (Rev. 10-2006)
                                                                                                                         

Form 941c (Rev. 10-2006)                                                                                       Page 3
                                                                                                                     
What’s New                                                 Corrections not required. You are not required to
                                                           correct errors previously reported as a monthly or daily
 
Line A. Three new check boxes have been added to           tax liability. For example, do not use Form 941c to
line A on page one for new Forms 944, 944(SP), and         correct amounts reported in line 15 of Form 941, line
944-SS. These forms are new for calendar year 2006.        13 of Form 944, line 15 of Form 943, or on Schedule B
Filers of these forms who wish to make adjustments         (Form 941), Form 943-A and Form 945-A. Also, you are
for prior years should check the appropriate box on        not required to correct amounts previously reported on
line A and file Form 941c with Form 944, 944(SP), or       lines 1 or 2 of Form 941 or Form 941-M; or line 1 of
944-SS.                                                    Form 941-SS or Form 943.
 
General Instructions                                        Statute of limitations. Generally, you may make an
                                                           adjustment only within three years of the return due
Purpose of form. Use Form 941c to provide                  date or the date the return was filed, whichever is later.
background information and certifications supporting       For the statute of limitations, the due date of Forms
prior period adjustments to income, social security,       941, 941-M, 941-SS, 943, 944, 944(SP), 944-SS, and
and Medicare taxes reported on Form 941, 941-M,            945 is April 15 of the year after the close of the tax
941-SS, 943, 944, 944(SP), 944-SS, or Form 945. File       year. For example, the four quarterly Forms 941 filed
it with the tax return on which you are claiming the       for 2004 are all treated as due on April 15, 2005. If
adjustment (Form 941, 943, 944, 945, etc.). You may        they were filed on or before April 15, 2005,
use Form 941c even though you filed the original           adjustments could be made for any of the quarterly
return on magnetic media or electronically.                returns for 2004 until April 15, 2008.
 Do not use Form 941c as a supporting statement for         
current period adjustments (for example, adjustment        Specific Instructions
for uncollected employee share of social security and
Medicare taxes on tips). No supporting statement is         Complete all applicable columns on the line for each
required for the fractions-of-cents, group-term life       return period that you are correcting. Show the total
insurance, and third-party sick pay adjustments. See       amount paid to all employees, not the amount for each
your form instructions.                                    individual employee. If you need more space, use
                                                           additional Forms 941c.
Federal income tax withholding errors. Generally,           
you are not permitted to correct federal income tax         If you use additional Forms 941c as continuation
withholding errors made in a prior calendar year.          pages, be sure that the total and net adjustment lines
However, you may make an adjustment to correct an          on the first form include the totals from the continuation
administrative error in a prior year. Refer to Pub. 15     pages. These lines are line 5 of Part II, lines 5 through 8
(Circular E), Employer’s Tax Guide, for more               of Part III, and lines 5 through 7 of Part IV.
information on correcting administrative errors.            Line A. Check the box for the return that you are
More information.        See Pub. 15 (Circular E), Pub. 51 adjusting. Check only one box. Use a    separate
(Circular A), Agricultural Employer’s Tax Guide, or your   Form 941c for each type of return (for example,
form instructions for more information about               Form 941 and Form 945).
adjustments.                                                Line B. Show the return period in which you are
How to use Form 941c.        Form 941c is notan            reporting tax adjustment(s). For example, if you are
amended return and must never be filed separately.         making an adjustment on Form 941 for the quarter
You must make adjustments on the return (for               ending June 30, 2006, enter 06-2006. File Form 941c
example, Form 941) for the period during which you         with Form 941 for this period. Do not show the return
discovered the error. There is no limit to the number      period(s) being corrected in this entry space.
of adjustments that you can make, and these                 Line C. Enter the date that you discovered the
adjustments can be for corrections to more than one        error(s). If you are making more than one correction
prior period. However, if you filed two or more types of   and the errors were not discovered at the same time,
tax returns that need correction (for example, Form        leave line C blank and explain in Part V. The date that
941 and Form 943), use a separate Form 941c for            you discover the error(s) is the date that your tax
each type of return. The net adjustment increases or       liability increases or decreases. Your deposits for this
decreases your tax liability for the period in which the   date must be adjusted accordingly. See your form
error was discovered and adjusted.                         instructions for more information.
 If your adjustment(s) results in an overpayment, you       Part I—Signature and certification. Part I applies to
may apply for a refund using Form 843, Claim for           wages only. If any adjustment is for an overpayment, it
Refund and Request for Abatement, instead of making        cannot be processed unless you check at least one
an adjustment as discussed above. If you choose to         box in Part I and you sign the certification. If you
file Form 843, you will receive a refund check (with       obtained written consents or statements from some
interest) instead of reducing your current employment      employees but you could not locate or secure the
tax liability (no interest). When filing Form 843, attach  cooperation of the remaining employees, check both
Form 941c or an equivalent statement.                      the second and third boxes. Provide a summary in
 If you did not file a return for one or more return       Part V of the amount of the adjustments for both the
periods, do not use Form 941c to report the                employees who provided statements and for those
 information. Instead, file the required returns.           who did not.

Form 941c (Rev. 10-2006)                                                                                     Page 4
                                                                                                                   
 You may make an adjustment for both the employer          you must file a Form W-2c, Corrected Wage and Tax
and employee shares of social security and Medicare        Statement, with the SSA and give copies to the
taxes for those employees who provided the required        employee for any social security correction made after
written statement. But you may make adjustments for        you filed his or her Form W-2 with the SSA. Do not
only the employer’s share for those employees who          send Form 941c (or a copy) to the SSA with
did not provide statements.                                Form(s) W-2c.
 Part II—Federal Income Tax Withholding (Including          Part IV—Medicare Tax Adjustment. Use this part to
Backup Withholding) Adjustment. Use this part to           correct Medicare wages and tips information that you
correct federal income tax withholding (including          reported in an earlier period. You may make
backup withholding) information that you previously        corrections to Medicare taxes reported in prior
reported. Show the total amount of income tax              calendar years as long as the statute of limitations has
withheld or required to be withheld.                       not expired (see Statute of limitations on page 3). If
 After the end of the year, you cannot adjust the          you are reducing Medicare taxes, be sure to read and
amounts reported as income tax withheld (including         check the appropriate boxes in Part I.
backup withholding) unless it is to correct an              You must file a Form W-2c with the SSA and give
administrative error. An administrative error is any error copies to the employee for any Medicare correction
that does not change the amount of income tax that         made after you filed Form W-2 with the SSA.
was actually withheld. For example, if the total income     
tax actually withheld was incorrectly reported due to a
mathematical computation or transposition error, this is   Paperwork Reduction Act Notice. We ask for the
an administrative error.                                   information on this form to carry out the Internal
 Except to correct an administrative error, you will not   Revenue laws of the United States. You are required to
                                                           give us the information. We need it to ensure that you
be allowed a refund or credit for any prior year
                                                           are complying with these laws and to allow us to figure
overpayment of income tax withheld (including backup
                                                           and collect the right amount of tax.
withholding). This is because the amount of
withholding shown on Form W-2, Wage and Tax                 You are not required to provide the information
Statement, Form W-2G, Certain Gambling Winnings, or        requested on a form that is subject to the Paperwork
Form 1099, is used as a credit on the employee’s or        Reduction Act unless the form displays a valid OMB
income recipient’s income tax return (Form 1040, etc.).    control number. Books or records relating to a form or
If you are making an administrative error adjustment       its instructions must be retained as long as their
for a period during a prior calendar year, provide an      contents may become material in the administration of
explanation in Part V.                                     any Internal Revenue law. Generally, tax returns and
                                                           return information are confidential, as required by Code
Part III—Social Security Tax Adjustment.   Use this
                                                           section 6103.
part to correct social security wages and tips
information that you reported in an earlier period. You     The time needed to complete and file this form will
may make corrections to social security taxes reported     vary depending on individual circumstances. The
in prior calendar years as long as the statute of          estimated average time is 9 hours and 12 minutes.
limitations has not expired (see Statute of limitations on  If you have comments concerning the accuracy of
page 3). If you are reducing social security taxes, be     this time estimate or suggestions for making this form
sure to read and check the appropriate boxes in Part I.    simpler, we would be happy to hear from you. You can
 Because Form W-2 is used by the Social Security           write to the IRS at the address shown in the Privacy
Administration (SSA) to post an employee’s social          Act and Paperwork Reduction Act Notice in the
security wages and tips to his or her earnings record,     instructions of the tax return with which you file
                                                           Form 941c.