Form
4977
Department of the Treasury- Internal Revenue Service
Tax period ended
(Rev. February 2002) Name
Schedule of Tax Liability
Employer Identification Number Telephone number (optional)
Number, street, and room or suite no.
City or town, state, and ZIP code
This form supports adjustments to: Form 1042 Form 940
Section I.
Line No. Period ending Tax liability for period (including any taxes assumed on Form(s) 1000)
Form 1042, Withholding Tax
Line No. Period ending Tax liability for period (including any taxes assumed on Form(s) 1000) Line No. Period ending Tax liability for period (including any taxes assumed on Form(s) 1000)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 April Mar. total March Feb. total Feb. Jan. total Jan.
7 15 22 31
21 22 23 24 25 May total May
7 15 22 31
41 42 43 44 45 Sept. total Sept.
7 15 22 30
7 15 22 28
26 27 28 29 30 June total June
7 15 22 30
46 47 48 49 50 Oct. total Oct.
7 15 22 31
7 15 22 31
31 32 33 34 35 July total July
7 15 22 31 1 7 15 August 22 31
51 52 53 54 55 56 57 58 59 60 Dec. total Dec Nov. total Nov.
7 15 22 31
7 15 22 30
36 37 38 39
7 15 22 31
Apr. total Aug. total 40 61 Total liability for year (add monthly total lines from above)
61
Section II.
Quarter First Second Third Fourth Total
Form 940, Unemployment Tax
Liability for Quarter (Do not include state liability)
Signature
Under penalties of perjury, I declare that I have examined the above liability schedule, and to the best of my knowledge and belief, it is true, correct, and complete. Date Title
Form 4977 (Rev. 02-2002)
Catalog Number 42142L