1501-21004344 TAXPAY® 15092
rom 941 for 2015: Employer’s QUARTERLY Federal Tax Return 450114
(Rev. January 2015) Depariment of the Treasury - internal Revenue Service OMB No. 1545-0029
CMoyerstritestarranter 5} Lal~ [a] [6] le }Lal a) lo} f6)) | peer
(Check .)
| VIRGINIANS FOR ALTERNATIVES TO (Check one.)
Name (not your trede nate) L
Quarter of 201
IX] 4: January, Febuary, Merch
Ria [A] 2: apr, Mey, June
[PO BOX 12222 | CO
Address | ar — Stew 5 ‘S:July, August, September
4: October, November, Decerrber
[RICHMOND | [wal E gaeea |) | paseeeeawemenens
City Slate ZIP code ele. Che ctMuMsisccwicin $47.
Foreign country name Foreign province/county Foreign postal code
Read the seParate instructions before you complete Form 941. Type or Print within the boxes.
HELIA Answer these ions for this quarter.
4 Number of employees who received wages, tips, or other compensation for the pay period a
including: Mar. 12 (Quarter 1), June 12 (Quarter 2), Sept. 12 (Quarter 3), or Dec. 12 (Quarter 4) 1
2 Wages, tips, andothercompensation . . « i e & & & a < # 2 13466 36
3 721 16
3 Federal income tax withheld irom wages, tips, and other compens:
4 If no wages, tips, and other re je ial security or Medicare tax oO Check and go to line 6.
Column 1 Column2
5a Taxable social security wages | 13466 136 | x 124 = | 1669 83
5b Taxable social security tips | 124 = |
5c Taxable Medicare wages & tips. | x .029= | 390 52
| | |
»_|x
13466 36 |
|
ao x 009 =
5d Taxable wages & tips subject to
iti Medicare Tax wi it
Se Add Cclumn 2 from fines Sa,6b,&c,andEd .. « 1 * ™ a “ . 5e 2060 35
5f Section 3121(q) Notice and Demand - Tax due on tips (see Fr . 5f .
6 Total taxes before adjustments. Add lines 3; 5e, and 5f. * sa & . . . 6
7 Current quarter’s adjustment for fractions ofcents F * % @ e = Ps vi
8 Current quarter's adjustment forsick pay . . . soe ee . . . 8
9 Current quarter's adjt for tips and group-t life it a e = Ps 9
.
10 Total taxes after adjustments. Combine lines 6thoughO =. we . . 10 2781 ,52
11 Total deposits for this quarter, including overpayment applied from a prior quarter and
overpayments applied trom Form 941-X, 941-X (PR), 944-X, 944-X (PR), or 944-X (SP) filed
inthecurentquarter. =... ee eH 2781 52
12 Balance due. If line 10 is more than line 11, enter the difference and see instructions - 2
18 Overpayment. Ifine 11 is more than line 10, enter difference Check one: CTaretvionetreun. ]serderetind
> You MUST complete both pages of Form 941 and SIGN it. Next >
For Privacy Act and Paperwork Reduction Act Notice, see the back of the Payment Voucher. Form 941 (Rev. 1-2015)
1501-21004344 TAXPAY® 15092
950214
Name (not your trade name) Employer identification number (EIN)
VIRGINIANS FOR ALTERNATIVES TO 54-1664106
HELE Tell us about your deposit schedule and tax ity for this quarter.
you are unsure about whether you are a ly depositor or i depositor, see Pub. 15
(Circular E), section 11.
14 Check one: [~] Line 10 on this return is less than $2,500 or line 10 on the return for the prior quarter was less than $2,500, and
dil not incur a $100,000 next-dav Geposit obligation during the current quarter. line 10 for he prior quarle vas less then
$2,500 but line 10 on this return is $100,000 or more, you must provide a record yay coed | tex ably. Hyou ere amonhly
schedule depositor, complete the deposit: ifyou are attach Schedule B
(Form 941). Goto Pat 3.
‘You were a monthly schedule depositor for the entire quarter. Enter your tax liability
for each month and tetal liability for the quarter, then go to Part 3.
Taxtabity: Month [nd
wove [___
vortns Ln
Total liability for quarter a must equal line 10.
x] You were a semiweekly schedule depositor for any part of this quarter. Complete Schedule B (Form 941),
Report of Tax Liability tor Semiweekly Schedule Depositors, and attach it to Form 941.
HE Tellus about your business. Ifa question does NOT apply to your business, leave it blank.
15 If your business has closed or you stopped paying wages « « “ we . - . - - L]check here, and
enter the final date you paid wages
16 Ifyou are a seasonal employer and you do net have to file a return for every quarter ofthe year. —. L_ICheck here.
MEGZUZA May we speak with your third-party designee?
Do you want to allow an employee, a paid tax preparer, or another person to discuss this return with the IRS? See the
instructions for details.
(J Yes. Designee’s name and phone number ( ) :
Select a 5-digit Personal Identiication Number (PIN) fo use when talking to IRS. DOI TE]
[I No.
Sign here. You MUST complete both pages of Farm 941 and SIGN it.
Under penalties of perjury, | declare that | have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, itis true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Print your |
Sign your name here
x name here REFERENCE COPY PREPARED BY PAYCHEX. Print your |
title here
oie | Besteeyime pone
Paid Preparer Use Only
Preparer’sname —_ | J prin | ]
sete. | ote [yy |
fens name (or yours] ] EIN [
Address | | Phone [( )
City | state | | z1P code |
theciiiyarmessiiempiyeds: « 9 «
Page2 Form 941 (Rev. 1-2015)
1501-21004344 TAXPAY® 15092
Schedule B (Form 941): 0311
Report of Tax Liability for Semiweekly Schedule Depositors
(Rev Jaruary 214) Defientrertcfihe Treasury - Internal Reverue Service’ OMB No. 1545-00:
Quart
EM yerienncaionramter ? | L4]— 2] [6] € ][4)2] 2 [6] veer
Neane Got yourradanare) [VIRGINIANS FOR ALTERNATIVES TO | [3 +: January, February, Merch
Catonciar Year [2 | [0] (| [5] (Also check quarter) [2 apr, May, dune
[T] seauy, August, September
Da ‘October, November, December
Use this schedule to show your TAX LIABILITY tor the quarter; DO NOT use it to show your deposits. When you file this form with Form
941 or Form 941-SS, DO NOT change your tax liability by adjustments reported on any Forms 941-X or 944-X. You must fill out this form and
attach it to Form 941 or Form 941-SS if you are a semiweekly schedule depositor or became one because your accumulated tax liabil
on any day was $100,000 or more. Write your daily tax liability on the numbered space that corresponds to the date wages were paid.
See Section 11 in Pub. 15 (Circular E), Employer’s Tax Guide, tor details.
lonth 1
[147 28) Tax liability for Month 1
1 Jo oI, alos 1
1 1 6 |
= = = = 441 64
. 14 . 1 . 27 s
_i “ Joa ‘
a 13 a 11 iJ 20! .
294_36|
ok . .
Month2
Tax liability for Month 2
1 . fe) = 471 . 5 | .
= 1 a 1 a 6 it
1243 58
LI 14 LI 1 . 27/ .
a_i si 621477] 9 ‘
«tal | «doo ai
62181),4 . «_Jod .
7 LI 15 a Px LI 31 LI
| i F
Month3
Tax liability for Month 3
1 | a_i alos .
10 1 26
= = = = 1096 «30
a 41 a 1! Ll 27| i]
l a_i a 474451] 04 ii
«Ia a (Li «Jad F
621s 794 » lai P|
i a_i a 5 oad |
| . .
Total for the quarter
Fill in your otal liability for the quarter (Month 1 + Nonth 2+ Month 3) >
Total must equal fine 1 cn Form 941 cr Form 9418S. 2781 152
For Pap Act rate i IR ‘Schedule B (Form 941) (Rev. 1-2014)
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