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Form (Rev. January 2011) (EIN)

941 for 2011:
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Employer’s QUARTERLY Federal Tax Return
Department of the Treasury — Internal Revenue Service

950111
OMB No. 1545-0029

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Employer identification number Name (not your trade name) Trade name (if any) Address

Report for this Quarter of 2011
(Check one.)

C J S CLEANING LLC

1: January,February, March 2: April, May, June 3: July, August, September

1480 BROOK RIDGE LN
Number Street Suite or room number

4: October, November, December Prior-year forms are available at www.irs.gov/form941.

TAYLORSVILLE
City

UT
State

84123
ZIP code

Read the separate instructions before you complete Form 941. Type or print within the boxes.

Part 1:
1 2 3 4 5a 5b 5c 5d 5e 6a 6bAnswer these questions for this quarter.
1 2 3
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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) Wages, tips, and other compensation . . . . . . . . . . . . . . . . . . . . . . . . .

Income tax withheld from wages, tips, and other compensation

. 0.
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00 00

If no wages, tips, and other compensation are subject to social security or Medicare tax Column 1 Taxable social security wages . Taxable social security tips . .
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Check and go to line 6e.

Taxable Medicare wages & tips.

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Column 2
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× .104 = × .104 =

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× .029 = . . . . . .

. . 0 .
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For 2011, the employee social security tax rateis 4.2% and the Medicare tax rate is 1.45%. The employer social security tax rate is 6.2% and the Medicare tax rate is 1.45%.

Add Column 2 line 5a, Column 2 line 5b, and Column 2 line 5c

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5d 5e

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Section 3121(q) Notice and Demand—Tax due on unreported tips (see instructions) Reserved for future use. Reserved for future use.

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Do Not Complete Lines 6a-6d.
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6c 6e 7 8 9 10 11 12a 12b 13 14 15
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Reserved for future use. Total taxes before adjustments (add lines 3, 5d, and 5e) . Current quarter’s adjustment for fractions of cents . Current quarter’s adjustment for sick pay .

Currentquarter’s adjustments for tips and group-term life insurance Total taxes after adjustments. Combine lines 6e through 9 . Total deposits, including prior quarter overpayments . . . . . . . . . . . .

COBRA premium assistance payments (see instructions)

. . . 0 . . 0 . . . . 0 .
Apply to next return.

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Number of individuals provided COBRA premium assistance . Add lines 11 and 12a. . . . . . . . . . . . . .

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13 14

Balance due. If line 10 is more than line 13, enter the difference and see instructions Overpayment. If line 13 is more than line 10, enter the difference You MUST complete both pages of Form 941 and SIGN it.

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Check one:

Send a refund.

Next ■▶
Cat. No. 17001Z Form 941 (Rev. 1-2011)

For PrivacyAct and Paperwork Reduction Act Notice, see the back of the Payment Voucher.

950211
Name (not your trade name) Employer identification number (EIN)

Part 2:

Tell us about your deposit schedule and tax liability for this quarter.

If you are unsure about whether you are a monthly schedule depositor or a semiweekly schedule depositor, see Pub. 15 (Circular E), section 11. 16 17 Checkone: Write the state abbreviation for the state where you made your deposits OR write “MU” if you made your deposits in multiple states.
Line 10 on this return is less than $2,500 or line 10 on the return for the preceding quarter was less than $2,500, and you did not incur a $100,000 next-day deposit obligation during the current quarter. If you meet the de minimis exception based on the prior...