HERE IS A LINK TO THE INSTRUCTIONS http://www.irs.gov/pub/irs-pdf/i8941.pdf
HERE IS A LINK TO THE FORM http://www.irs.gov/pub/irs-pdf/f8941.pdf
Worksheet One Form 8941
Line 1 of Form 8941 total of Col A
Col A Col B Col C
3 Methods: Actual hrs
worked, days worked or
weeks worked (this
Not owner, partner, shows hrs wrked)
shareholder, family Enter 0 for Enter 0 for
members, minister, seasonal < seasonal <
seasonal < 120 days, 120 days 120 days
household empl nothing over
2,080
Employee Hours of Employee Wages Paid-
Service (includes wages for this purpose
vacation, holiday, mean wages subject to
Individuals Considered Employees illness) Medicare tax
1 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
Totals 0 0
Line 1 Form 8941 - Col A # employees
pdf/i8941.pdf
pdf/f8941.pdf
Worksheet Two Form 8941
Col A Col B Col C
Not owner, partner, For WI
shareholder, family Enter
members, minister, Only prem paid Single (Empl Only)
seasonal < 120 days, by employer $5,222
Family Coverage
household empl (see instructions) $12,819
S = Single F
= Family
Employees
Enrolled Individuals Considered Coverage Status Employer Premiums Employer State
Employees Single or Family Paid Average Premiums
1 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
Totals 0 0
Line 13 Form 8941 Line 4 Form 8941 Line 5 Form 8941
(total # employees listed Col A)
Col D
Enter 0 for
seasonal <
120 days
nothing over
2,080
Enrolled Employee
Hours of Service
0
Col D / 2080
0
Line 14 Form 8941