Fill in a Valid Massachusetts M 941A Form

M-941A

MASSACHUSETTS DEPARTMENT OF REVENUE

A

EMPLOYER’S ANNUAL RETURN OF INCOME TAXES WITHHELD

YOU MUST FILE THIS FORM EVEN THOUGH NO TAX MAY BE DUE.

NUMBER OF EMPLOYEES FROM

WHOM TAXES WERE WITHHELD:

FEDERAL IDENTIFICATION NUMBER

BE SURE THIS RETURN COVERS

FOR YEAR

THE CORRECT PERIOD

Note: An entry must be made in each line. Enter “0,” if applicable.

IF INCORRECT, SEE INSTRUCTIONSCheck. DOhereNOTif EFTALTERpayment. .

1. AMOUNT WITHHELD

BUSINESS

NAME

IF ANY

INFOR-

2. ADJUSTMENT FOR PRIOR

BUSINESS

ADDRESS

AMOUNT WITHHELD*

MATION IS

INCORRECT,

CITY/SEETOWN

STATE

ZIP

3. AMOUNT DUE AFTER ADJUST-

INSTRUC-

MENT (NOT LESS THAN “0”)

TIONS.

Check if final return and you wish to close your withholding tax account.

4. PENALTIES

5. INTEREST

6. TOTAL AMOUNT DUE

Return is due with payment on or before the 31st day of January following the year indicated above. Make check

(ADD LINES 3, 4 AND 5)

payable to Commonwealth of Mass. Mail to: Mass. Dept. of Revenue, PO Box 7042, Boston, MA 02204.

I declare under the penalties of perjury that this return (including any accompanying schedules and statements)

CHECK HERE IF USING THE BACK OF THIS FORM:

has been examined by me and to the best of my knowledge and belief is a true, correct and complete return.

*Explain any adjustment on reverse or it will be disallowed. Adjustment

Signature

Title

Date

must be from immediate prior period.

LINE 2 ADJUSTMENT INFORMATION

STATE REASON FOR ADJUSTMENT REQUEST:

AS REPORTED

CORRECTED

AMOUNT

WITHHELD

ADJUSTMENT

PRIOR PERIOD

AMOUNT

PAID

REPORTED UNDER

FED. IDENT. NO.

REPORTING

PERIOD IN ERROR

4.5M 7/00 00-B02

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