Name (not your trade name)

Name (not your trade name) Employer uleniew:abon number (E1N) Correcting (Warta (1.2.3.4) Correcting calendar yeas (YYYY) CFI 22. Check here if any corrections you entered on a line include both underreported and overreported amounts. your underreported and overreported amounts on line 24. K 23. Check here ii any corrections invoke reclassified workers. Explain on line 24. 24. You must give us a detailed explanation of how you determined your corrections. Sign here. You must complete all three pages of this form and sign it. I • Explain your corrections for this quarter. See the instructions. Explain both Und r penalties of perjury. I declare that I have filed an original Form 941 or Form 941-SS and that I have examined this adjus accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declarati taxpayer) is based on all information of which pupate( has any knowledge. Sign your name here Date ted return or claim, including on of prepares (other than EFTA01219700