During the third calendar quarter of 20--, Bayview Inn, owned by Diane R. Peters, employed the persons listed below. Also given are the employees' salaries or wages and the amount of tips reported to the owner. The tips were reported by the 10th of each month. The federal income tax and FICA tax to be withheld from the tips were estimated by the owner and withheld equally over the 13 weekly pay periods. The employer's portion of FICA tax on the tips was estimated as the same amount.

Employees are paid weekly on Friday. The following paydays occurred during this quarter:

Taxes withheld for the 13 paydays in the third quarter follow:

Based on the information given, complete Form 941 on the following pages for Diane R. Peters. Phone number: (901) 555-7959

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Quarter's Quarter's Quarter's Quarters OASDI $1,209.00 $78,000lyear 19,500.00 282.75 $1,500.00 Grant Frazier Joseph LaVange Susanne Ayers 5 10,400.00 2,240.90 783.77 2,493.10 2,640.30 4 Helen Woods David Harad 104,975.00 $10,078.30 $7,133.36 $1,668.55 $9,100.00 July August September 4 weekly paydays 5weekly paydays4 weekly paydays Employees' Federal Income Tax FICA Taxes Withheld on Wages Weekly FICA Taxes on Tips Weekly OASDI HI OASDI HI S700 per week Employees' $500.65 117.1 Employees' $48.07 $11.24 Employer's 500.65117.09 Employer's 48.07 11.24 Fom 941 for 20--: Employer's QUARTERLY Federal Tax Return Dapartmant of the Treaaury - Intamal Rlawanue Service OMB No. 1545-0020 Report for this Quarter of Check ona Emplayer identhication number (EIN DIANE R. PETERS Name pot your tradio nana) 1:January, February, March 2 April, May, June name anyBAYVIEW INN Juy.August, September 4: October, November, December 404 UNION AVE Instructons and prior year forms are avallable at www.irs.gowrorme41 MEMPHIS 38112 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 ), June 12 (Quarter 2), Sept. 12 (Quarter 3), or Dec. 12 (Quarter 4 Wages, tips, and other compensation 3 4 2 Federal income tax withheld from wages, tips, and other compensation If no wages, tips, and other compensation are subject to social security or Medicare tax Check and go to line Column 1 Column 2 5a Taxable social security wages 5b Taxable social security tips . . . 5c Taxable Medicare wages & tips. 5d Taxable wages & tips subject to x124- x.124- к.029- x 009- Additional Medicare Tax withholding 5e Add Column 2 from lines 5a, 5b, 5c, and 5d 5f Section 3121(4) Notice and Demand Tax due on unreported tips (see instructions) 6 Total taxes before adjustments. Add ines 3, 5e, and 5f 7 Current quarter's adjustment for fractions of cents 8 Curnt quarter's adjustment for sick pay 9 Current quarter's adjustments for tips and group-term life insurance 10 Total taxes after adjustments. Combine lines 6 through 9 5f 10 11 Total deposits for this quarter, including overpayment applied from a prior quarter and overpayments applied from Form 941-K 941-X (PR), 944-Х, 944-X PR), or 944-X (SP) filed in the current quarter 12 Balance due. If line 10 is more than line 11, enter the diffierence and see instructions 12 13 Overpayment. If line 11 is more than ine 10, enter the difference 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 Form 941 Raw. 12015 Cat No. 170012 your idantification number (EIN DIANE R. FETERS 00-0003607 Part 2: Tell us about your deposit schedule and tax liability for this quarter It you are unsure about whether you are a monthly schedule deposltor or a semiweekly schedule deposltor, see Pub. 15 (Circular E), section 11. Lino 10 on this return is less than S2.500 or line t0 on the return for the prior quarter was less than S2500, and you did not incur a 100,000 next-day daposit obligation during the current quartor. If ino 10 for the prior quartar was lass than $2,s00 but ina 10 on this raturn 3100,000 or mora, you must provida a racord of your fedaral tax schodulo balow; i you aro a saniwookdy schadula dapositor, attach Schodulo B Form 941). Go to Purt 3. 14 Check one: you aro a monthly schadula daposior, complate tha daposi You were a monthly schedule deposltor for the entire quarter. Enter your tax lablity for each month and total llablity for the quarter, then go to Part 3. Month 1 Month 2 Month 3 Total lability for quarter Tax llablity: Total must equal line 10. Ц You were a semiweekly schedule depositor for any part of this quarter. Complete Schedule B (Form 941). Report of Tax Llability 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. 15 If your business has closed or you stopped paying wages Check here, and enter the final date you paid wages 16 If you are a seasonal employer and you do not have to tle 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 pald tax preparer, or another person to discuss this retum wtth the IRS? See the Instructions for detalls Yes. Daslgnee's name and phone number Select a 5-digit Personal Identinication 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 Undor panaltios of parjury, I daclaro that I havo axaminad this robum, including accompanying schadulas and stataments, and to the beat of my knowlodga and balof, it is true,corroct, and complata Daclaration of proparor (othar than taxpayor) is basad on all information of which proparor has any knowladga Print your name here Print your itle here Sign your name here Date Best daytime phone Paid Preparer Use Only Preparer's name Preparer's signature Arm's name (or Check It you are self-employed PTIN Date EIN AddresS Phone city State ZIP code Rav. 1-2015)