Using a blank Form 941, complete Part 1, lines 1?6, using the following information:

Total employees during the first quarter	3
Total wages during the first quarter, none came from tips	$26,800.15
Federal income tax withheld	$2,025.00

Form 941

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Fom 941 for 201X: Employer's QUARTERLY Federal Tax Return 450117 Department of the Treasury - Intemal Revenue Service OMB No. 1545-0029 2 Report for this Quarter of 201X (Check one) Employer identification nunber (EN 2 Name net your trede nane Jordan Lewis 1: Jaruary, February, March 2: April, May, June Trade name fany House of Colors 3: July, August, September Address 123 Pine Street Number X 4: October, November, December See Sute or room umber Instructions and prior year forms are available at www.irs.gow/form941. Concord MA 01742 City State ZP code Foreign oountry neome Foreign provincecounty Foreign postal oode 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 4 2 Wages, tips, and other compensation 53432. 57 3 Federal income tax withheld from wages, tips, and other compensation 3 6606. 00 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.. 53432. 57 x 0.124 - 6625. 64 5b Taxable social security tips. x 0.124 - 5c Taxable Medicare wages & tips. 53432. 57 x 0.029 - 1549. 54 5d Taxable wages å tips subject to Additional Medicare Tax withholding x 0.009 = 5e Add Column 2 from lines 5a, 5b, 5c, and 5d 5e 8175. 18 51 Section 3121(q) Notice and Demand-Tax due on unreported tips (see instructions) 51 6 Total taxes before adjustments. Add lines 3, 5e, and 5f 14781. 18 7 Current quarter's adjustment for fractions of cents Current quarter's adjustment for sick pay 8 Current quarter's adjustments for tips and group-term life insurance 10 Total taxes after adjustments. Combine lines 6 through 9 10 14781. 18 11 Qualified small business payroll tax credit for increasing research activities. Atach Form 8974 11 12 Total taxes after adjustments and credits. Subtract line 11 from line 10. 12 14781. 18 Total deposits for this quarter, including overpayment applied from a prior quarter and overpayments applied from Form 941-X, 941-X (PR), 944-X, or 944-X (SP) filed in the current quarter 13 13 14781. 18 14 Balance due. F line 12 is more than line 13, enter the difference and see instructions 14 Overpayment. I ine 13 is more than line 12, enter the difference You MUST complete both pages of Form 941 and SIGN it. 15 Check one: UApply to net retun. Senda retund. Next For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher. Ct. No. 170012 Form 941