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Part 1: Answer these questions for this quarter. 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 2 86,125.05 3 Federal income tax withheld from wages, tips, and other compensation 3 13144.58 4 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 x 0.124 = X . 5b Taxable social security tips x 0.124 = x 0.029 = X 5c Taxable Medicare wages & tips. 5d Taxable wages & tips subject to x Additional Medicare Tax withholding x 0.009 x . 5e Add Column 2 from lines 5a, 5b, 5c, and 5d 2 .X 5e 5f Section 3121(9) Notice and Demand-Tax due on unreported tips (see instructions) 5f 6 Total taxes before adjustments. Add lines 3, 5e, and 5f. X6 7 Current quarter's adjustment for fractions of cents X 7 8 Current quarter's adjustment for sick pay. 8 8 9 Current quarter's adjustments for tips and group-term life insurance 9 10 Total taxes after adjustments. Combine lines 6 through 9 X 10 11 Qualified small business payroll tax credit for increasing research activities. Attach Form 8974 11 12 Total taxes after adjustments and credits. Subtract line 11 from line 10 .X 12 13 Total deposits for this quarter, including overpayment applied from a prior quarter and overpayments applied from Form 941-X, 941-X (PR) or 944-X (SP) filed in the current quarter 13 X 14 Balance due. If line 12 is more than line 13, enter the difference and see instructions 14 15 Overpayment. If line 13 is more than line 12, enter the difference 1st Quarter n/a 2nd Quarter n/a 3rd Quarter n/a 4th Quarter n/a n/a $ 3,796.00 n/a n/a $ 3,796.00 n/a n/a $ 3,796.00 n/a n/a $ 2,920.00 n/a n/a n/a n/a n/a $ 1,637.09 $ 5,433.09 S 208.00 $ 255.32 $ 336.83 $ 78.78 S 326.04 S $ 1,637.09 S 5,433.09 S 208.00 S 255.32 $ 336.83 $ 78.78 S 326.04 S $ 1,637.09 $ 5,433.09 $ 208.00 $ 255.32 $ 336.83 $ 78.78 $ 326.04 $ $ 1,259.30 $ 4,179.30 S 160.00 $ 196.40 $ 259.10 $ 60.60 $ 250.80 $ $195.00 $ 91.00 $ 195.00$ 91.00 $195.00$ 91.00 $ 150.00$ 70.00 $ 3,942.12 $ 3,942.12 $ 3,942.12 $ 3,032.40 Employee Earnings Record Name David Alexander Marital Status Single Address 1 1 Freedom Blvd. Durham, NC 27701 Fed. Withholding Allow. State Withholding Allow. 1 SS# 454-54-5454 Earnings Deductions Pay Period Ending Regular Hours Worked Regular Pay Rate Regular Wages overtime Pay Rate vertime Wages ederal Withholding Tax tate Withholding Tax ocial Security Tax Medicare Tax Retirement Contribution Gross Pay Charitable contribution ife Insurance Additional Withholding Check Number 1st Quarter n/a 2nd Quarter n/a 3rd Quarter n/a 4th Quarter n/a n/a n/a n/a n/a $ 52,650.00 n/a $ 52,650.00 n/a $ 52,650.00 n/a $ 40,500.00 n/a n/a n/a n/a n/a $ $. $. $ $ 52,650.00 $ 9.515.48$ 2,316.60 $ 3,264.30 S 763.49 S 6,318.00 S $ 52,650.00 $ 9,515.48$ 2,316.60 $ 3,264.30 $763.49 $ 6,318.00 $ $ 52,650.00 S 9,515.48 $ 2,316.60 $ 1,711.20 $ 763.49 $ 6,318.00 S $ 40,500.00 $ 7,319.60 $ 1,782.00 $ $ 587.30 $ 4,860.00 $ $ 260.00 $ $ 260.00 $ $ 260.00 $ $ 200.00 S $ 30,212.13 $ 30,212.13 $ 31,765.23 $ 25,751.10 - - Employee Earnings Record Name Michael Sierra Marital Status Married Address Fed. Withholding Allow. 200 Mississippi Road Durham, NC 27701 State Withholding Allow. 3 SS# 232-32-3232 Earnings Deductions Pay Period Ending 333 Regular Hours Worked RB Regular Pay Rate & & & Regular Wages 13 overtime Pay Rate Overtime Wages 9&&&Federal Withholding Tax 1. Retirement Contribution Check Number Net Pay 1st Quarter 2nd Quarter n/a 3rd Quarter n/a 4th Quarter n/a $ 31,850.00 n/a $ 31,850.00 n/a $ 31,850.00 n/a $ 24,500.00 n/a n/a n/a n/a n/a $ $ IS IS. $ 31,850.00 $ 3,220.10 $ 1,560.00 $ 1,934.40 $452.40 $ $ 31,850.00$ 3,220.10 $ 1,560.00 $ 1,934.40 $ 452.40S $ 31,850.00 $ 3,220.10 $ 1,560.00 $ 1,934.40 $452.40 $ $ 24,500.00 $ 2,477.00 $ 1,200.00 $ 1,488.00 $ 348.00 $ $ 260.00 $ 65.00 $ 650.00 $ 260.00 $ 65.00 $ 650.00 $ 260.00 $ 65.00 $ 650.00 $ 200.00 $ 50.00 $ 500.00 $ 23,708.10 $ 23,708.10 $ 23,708.10 $ 18,237.00 Part 1: Answer these questions for this quarter. 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 2 86,125.05 3 Federal income tax withheld from wages, tips, and other compensation 3 13144.58 4 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 x 0.124 = X . 5b Taxable social security tips x 0.124 = x 0.029 = X 5c Taxable Medicare wages & tips. 5d Taxable wages & tips subject to x Additional Medicare Tax withholding x 0.009 x . 5e Add Column 2 from lines 5a, 5b, 5c, and 5d 2 .X 5e 5f Section 3121(9) Notice and Demand-Tax due on unreported tips (see instructions) 5f 6 Total taxes before adjustments. Add lines 3, 5e, and 5f. X6 7 Current quarter's adjustment for fractions of cents X 7 8 Current quarter's adjustment for sick pay. 8 8 9 Current quarter's adjustments for tips and group-term life insurance 9 10 Total taxes after adjustments. Combine lines 6 through 9 X 10 11 Qualified small business payroll tax credit for increasing research activities. Attach Form 8974 11 12 Total taxes after adjustments and credits. Subtract line 11 from line 10 .X 12 13 Total deposits for this quarter, including overpayment applied from a prior quarter and overpayments applied from Form 941-X, 941-X (PR) or 944-X (SP) filed in the current quarter 13 X 14 Balance due. If line 12 is more than line 13, enter the difference and see instructions 14 15 Overpayment. If line 13 is more than line 12, enter the difference 1st Quarter n/a 2nd Quarter n/a 3rd Quarter n/a 4th Quarter n/a n/a $ 3,796.00 n/a n/a $ 3,796.00 n/a n/a $ 3,796.00 n/a n/a $ 2,920.00 n/a n/a n/a n/a n/a $ 1,637.09 $ 5,433.09 S 208.00 $ 255.32 $ 336.83 $ 78.78 S 326.04 S $ 1,637.09 S 5,433.09 S 208.00 S 255.32 $ 336.83 $ 78.78 S 326.04 S $ 1,637.09 $ 5,433.09 $ 208.00 $ 255.32 $ 336.83 $ 78.78 $ 326.04 $ $ 1,259.30 $ 4,179.30 S 160.00 $ 196.40 $ 259.10 $ 60.60 $ 250.80 $ $195.00 $ 91.00 $ 195.00$ 91.00 $195.00$ 91.00 $ 150.00$ 70.00 $ 3,942.12 $ 3,942.12 $ 3,942.12 $ 3,032.40 Employee Earnings Record Name David Alexander Marital Status Single Address 1 1 Freedom Blvd. Durham, NC 27701 Fed. Withholding Allow. State Withholding Allow. 1 SS# 454-54-5454 Earnings Deductions Pay Period Ending Regular Hours Worked Regular Pay Rate Regular Wages overtime Pay Rate vertime Wages ederal Withholding Tax tate Withholding Tax ocial Security Tax Medicare Tax Retirement Contribution Gross Pay Charitable contribution ife Insurance Additional Withholding Check Number 1st Quarter n/a 2nd Quarter n/a 3rd Quarter n/a 4th Quarter n/a n/a n/a n/a n/a $ 52,650.00 n/a $ 52,650.00 n/a $ 52,650.00 n/a $ 40,500.00 n/a n/a n/a n/a n/a $ $. $. $ $ 52,650.00 $ 9.515.48$ 2,316.60 $ 3,264.30 S 763.49 S 6,318.00 S $ 52,650.00 $ 9,515.48$ 2,316.60 $ 3,264.30 $763.49 $ 6,318.00 $ $ 52,650.00 S 9,515.48 $ 2,316.60 $ 1,711.20 $ 763.49 $ 6,318.00 S $ 40,500.00 $ 7,319.60 $ 1,782.00 $ $ 587.30 $ 4,860.00 $ $ 260.00 $ $ 260.00 $ $ 260.00 $ $ 200.00 S $ 30,212.13 $ 30,212.13 $ 31,765.23 $ 25,751.10 - - Employee Earnings Record Name Michael Sierra Marital Status Married Address Fed. Withholding Allow. 200 Mississippi Road Durham, NC 27701 State Withholding Allow. 3 SS# 232-32-3232 Earnings Deductions Pay Period Ending 333 Regular Hours Worked RB Regular Pay Rate & & & Regular Wages 13 overtime Pay Rate Overtime Wages 9&&&Federal Withholding Tax 1. Retirement Contribution Check Number Net Pay 1st Quarter 2nd Quarter n/a 3rd Quarter n/a 4th Quarter n/a $ 31,850.00 n/a $ 31,850.00 n/a $ 31,850.00 n/a $ 24,500.00 n/a n/a n/a n/a n/a $ $ IS IS. $ 31,850.00 $ 3,220.10 $ 1,560.00 $ 1,934.40 $452.40 $ $ 31,850.00$ 3,220.10 $ 1,560.00 $ 1,934.40 $ 452.40S $ 31,850.00 $ 3,220.10 $ 1,560.00 $ 1,934.40 $452.40 $ $ 24,500.00 $ 2,477.00 $ 1,200.00 $ 1,488.00 $ 348.00 $ $ 260.00 $ 65.00 $ 650.00 $ 260.00 $ 65.00 $ 650.00 $ 260.00 $ 65.00 $ 650.00 $ 200.00 $ 50.00 $ 500.00 $ 23,708.10 $ 23,708.10 $ 23,708.10 $ 18,237.00

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