Form 941 for 2020:
(Rev. January 2020)
Employer’s QUARTERLY Federal Tax Return
Department of the Treasury — Internal Revenue Service
950117
OMB No. 1545-0029
2 7 — 7 7 2 9 7 3 0 Report for this Quarter of 2020
Employer identification number (EIN)
(Check one.)
Name (not your trade name) ANNISSIA Y PATE ✖ 1: January, February, March
2: April, May, June
Trade name (if any)
3: July, August, September
Address 1458 Swinger Dr 4: October, November, December
Number Street Suite or room number
Go to www.irs.gov/Form941 for
instructions and the latest information.
Dayton OH 45417
City State ZIP code
Foreign country name Foreign province/county Foreign postal code
Read the separate instructions before you complete Form 941. 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: Mar. 12 (Quarter 1), June 12 (Quarter 2), Sept. 12 (Quarter 3), or Dec. 12 (Quarter 4) 1 1
2 Wages, tips, and other compensation . . . . . . . . . . . . . . . . . 2 91425 . 10
3 Federal income tax withheld from wages, tips, and other compensation . . . . . . 3 17003 . 26
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 . . 96973 . 50 × 0.124 = 12024 . 71
5b Taxable social security tips . . . . × 0.124 = .
5c Taxable Medicare wages & tips. . 96973 . 50 × 0.029 = 2812 . 23
Taxable wages & tips subject to
5d
Additional Medicare Tax withholding . × 0.009 = .
5e Add Column 2 from lines 5a, 5b, 5c, and 5d . . . . . . . . . . . . . . . 5e 14836 . 94
5f Section 3121(q) Notice and Demand—Tax due on unreported tips (see instructions) . . 5f .
6 Total taxes before adjustments. Add lines 3, 5e, and 5f . . . . . . . . . . . . 6 31840 . 20
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 31840 . 20
11 Qualified small business payroll tax credit for increasing research activities. Attach Form 8974 11 .
12 Total taxes after adjustments and credits. Subtract line 11 from line 10 . . . . . . . 12 31840 . 20
Total deposits for this quarter, including overpayment applied from a prior quarter and
13
overpayments applied from Form 941-X, 941-X (PR), 944-X, or 944-X (SP) filed in the current quarter 13 31840 . 20
14 Balance due. If line 12 is more than line 13, enter the difference and see instructions . . . 14 0 . 00
15 Overpayment. If line 13 is more than line 12, enter the difference . Check one: Apply to next return. Send a refund.
▶ You MUST complete both 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. 1-2020)
950217
Name (not your trade name) Employer identification number (EIN)
ANNISSIA Y PATE 27-7729730
Part 2: Tell us about your deposit schedule and tax liability for this quarter.
If you are unsure about whether you are a monthly schedule depositor or a semiweekly schedule depositor, see section 11
of Pub. 15.
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 are a monthly schedule
depositor, complete the deposit schedule below; if you are 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 10613 . 40
Month 2 10590 . 40
Month 3 10636 . 40
Total liability for quarter 31840 . 20 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.
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 / / .
18 If you are a seasonal employer and you don’t have to file a return for every quarter of the year . . Check here.
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 both pages of Form 941 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
name here ANNISSIA Y PATE
Sign your
name here Print your
title here Owner
Date / / Best daytime phone 8594740170
Paid Preparer Use Only Check if you are 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 2 Form 941 (Rev. 1-2020)
