Free Form 945-X (Rev. January 2009) - Federal

Form (January 2009)

945-X:

Adjusted Annual Return of Withheld Federal Income Tax or Claim for Refund
Department of the Treasury -- Internal Revenue Service -- OMB No. 1545-1430

Employer identification number (EIN)

Return You Are Correcting ...
Enter the calendar year of the return you are correcting: (YYYY)

Name (not your trade name)

Trade name (if any)

Address
Number Street Suite or room number

Enter the date you discovered errors: / /

City

State

ZIP code

(MM / DD / YYYY)

Use this form to correct errors made on Form 945, Annual Return of Withheld Federal Income Tax, for one year only. Please type or print within the boxes. Do not attach this form to Form 945. You MUST complete both pages. Read the instructions before you complete this form.

Part 1: Select ONLY one process.

1. Adjusted return of withheld federal income tax. Check this box if you underreported amounts. Also check this box if you overreported amounts and you would like to use the adjustment process to correct the errors. You must check this box if you are correcting both underreported and overreported amounts on this form. The amount shown on line 5, if less than 0, may only be applied as a credit to your Form 945 for the tax period in which you are filing this form. 2. Claim. Check this box if you overreported amounts only and you would like to use the claim process to ask for a refund or abatement of the amount shown on line 5. Do not check this box if you are correcting ANY underreported amounts on this form.

Part 2: Enter the corrections for this year. If any line does not apply, leave it blank.
Column 1
Total corrected amount (for ALL payees)

Column 2
Amount originally reported or as previously corrected (for ALL payees)

Column 3
Difference (If this amount is a negative number, use a minus sign.)

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3. Federal income tax withheld (from line 1 of Form 945) 4. Backup withholding (from line 2 of Form 945)

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5.

Total. Combine the amounts in lines 3 and 4 of Column 3 If line 5 is less than 0:

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If you checked line 1, this is the amount you want applied as a credit to your Form 945 for the tax period in which you are filing this form. If you checked line 2, this is the amount you want refunded or abated. If line 5 is more than 0, this is the amount you owe. Pay this amount when you file this return. For information on how to pay, see Amount You Owe in the instructions for line 5.

Next
For Paperwork Reduction Act Notice, see the instructions.
Cat. No. 20336X Form

945-X

(1-2009)

Name (not your trade name)

Employer identification number (EIN)

Calendar Year (YYYY)

Part 3: Explain your corrections for this year. 6. Check here if any corrections you entered on a line include both underreported and overreported amounts. Explain both your underreported and overreported amounts on line 7. You must give us a detailed explanation of how you determined your corrections. See the instructions.

7.

Part 4: Sign here. You must complete both pages of this form and sign it.
Under penalties of perjury, I declare that I have filed an original Form 945 and that I have examined this adjusted return or claim and any schedules or statements that are attached, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Sign your name here

Print your name here Print your title here / / Best daytime phone ( Check if you are self-employed Preparer's SSN/PTIN Date EIN Phone State ZIP code
Form

Date

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Paid preparer's use only
Preparer's name Preparer's signature Firm's name (or yours if self-employed) Address City
Page

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945-X

(1-2009)