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Check and go to line 6 . 11b Nonrefundable portion of credit for qualified sick and family leave wages for leave taken before You MUST complete all three pages of Form 941 and SIGN it. Next For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher. Cat. No. 17001Z Form 941 (Rev. 3-2022) Name (not your trade name) Employer identification number (EIN) CARLOS CRUZ 00-0006509 Part 1: Answer these questions for this quarter. (continued) 11d Nonrefundable portion of credit for qualified sick and family leave wages for leave taken after 11e Nonrefundable portion of COBRA premium assistance credit (see instructions for applicable quarter) 11e 11 Number of individuals provided COBRA premium assistance 11g Total nonrefundable credits. Add lines 11a,11b,11d, and 11e 12 Total taxes after adjustments and nonrefundable credits. Subtract line 11g from line 10 13a Total deposits for this quarter, including overpayment applied from a prior quarter and overpayments applied from Form 941X,941X(PR),944X, or 944X(SP) filed in the current quarter Cruz Company has gathered the information needed to complete its Form 941 for the quarter ended September 30, 20--. Using the information presented below, complete Part 1 of Form 941. Note: Round all values to the nearest cent and then use rounded amounts in subsequent computations. Use minus sign to indicate a deduction. If line 7 is zero, for grading purposes only, enter a zero. - \# of employees for pay period that included September 12=14 employees - Wages paid third quarter =$79,131.21 - Federal income tax withheld in the third quarter =$9,495.75 - Taxable social security and Medicare wages =$79,131.21 - Total tax deposits for the quarter =$21,602.82 Note: Lines 5a and 5c of Form 941, tax on total taxable wages, are computed by multiplying by the combined tax rate for both employer and employee. Small differences due to rounding may occur between this total and the total taxes withheld from employees each pay period and the amount of the employer's taxes calculated each pay period. This difference is reported on line 7 as a deduction or an addition as "Fractions of Cents." Hint: Line 7 instructions. Fill in Form 941 through line 6, and then fill in Part 2, line 16, Schedule B. Take that information and fill in line 10. Note that Lines 6 and 10 must equal. If the amounts are not the same, correct by entering amount to make equal on line 7 . Line 7 differences are caused by how calculations are made on Form 941 and the amounts withheld from employee's earning plus the employer's payroll tax amounts each pay period. 13b Reserved for future use 13b 13c 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 13e 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 Refundable portion of COBRA premium assistance credit (see instructions for applicable quarter) . . 13f 13g Total deposits and refundable credits. Add lines 13a,13c,13e, and 13f 139 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. Page 2 Form 941 (Rev. 3-2022) 941 for 20--: Employer's QUARTERLY Federal Tax Return March 2022) Department of the Treasury - Internal Revenue Service OMB No. 1545-0029

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