Form 7200 (2021) - PDF Reader Pro

Form 7200
(Rev. April 2021)

Advance Payment of Employer Credits Due to COVID-19
OMB No. 1545-0029
Department of the Treasury ▶ Go to www.irs.gov/Form7200 for instructions and the latest information.
Internal Revenue Service
Name (not your trade name) Employer identification number (EIN)
Trade name (if any) Applicable calendar quarter in 2021

(check only one box) Caution: See
instructions before completing to
Number, street, and apt. or suite no. If a P.O. box, see instructions. determine if the credits and advance are
available for the applicable quarter in 2021.
City or town, state, and ZIP code. If a foreign address, also complete spaces below. (See instructions.)
(2) April, May, June
Foreign country name Foreign province/county Foreign postal code (3) July, August, September
(4) October, November, December
Name on employment tax return (third-party payer) that will report the wages and credits related to the advance you’re EIN on employment tax return (if other than your own)
requesting in Part II (leave blank if return is filed under your name and EIN). See instructions.
Part I Tell Us About Your Employment Tax Return

A Check the box to indicate which employment tax return form you file (or will file for 2021). Check only one box.
(1) 941, 941-PR, or 941-SS (2) 943 or 943-PR (3) 944 (4) CT-1
B Enter the total number of employees to whom you paid qualified wages eligible for the employee retention credit this quarter ▶
C Amount reported on line 2 of your most recently filed Form 941 (or wages reported on Schedule R (Form 941), column (d), by
your third-party payer (see instructions)). If you file a different employment tax return or have never filed one, see instructions ▶
D Tax period of most recently filed Form 941 (for example, “Q4 2020”) or annual employment tax return (for example, “2020”) ▶
E If you’re requesting an advance payment of the employee retention credit (Part II, line 1), enter the average
number of full-time employees you had in 2019 (or 2020 if your business wasn’t in existence in 2019).
Aggregation rules apply. See instructions . . . . . . . . . . . . . . . . . . . . . . ▶
F If you’re requesting an advance payment for qualified sick and/or family leave wages (Part II, lines 2 and/or 3), enter the number
of employees you had when qualified leave was taken during the quarter for the advance requested. See instructions . . ▶
G Number of individuals provided COBRA premium assistance during the quarter for the advance requested . . ▶
H If you’re eligible for the employee retention credit solely because your business is a recovery startup business,
check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶
Part II Enter Your Credits and Advance Requested
1 Total employee retention credit for the quarter. Don’t enter more than the amount eligible to be advanced
for the quarter. See instructions . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Total qualified sick leave wages eligible for the credit and paid this quarter. See instructions . . . . . 2
3 Total qualified family leave wages eligible for the credit and paid this quarter. See instructions . . . . 3
4 Total COBRA premium assistance provided this quarter. See instructions . . . . . . . . . . . 4
5 Add lines 1, 2, 3, and 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Total amount by which you have already reduced your federal employment tax
deposits for these credits for this quarter. Enter as a positive number . . . . 6
7 Total advanced credits requested on previous filings of this form for this quarter . 7
8 Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
9 Advance requested. Subtract line 8 from line 5. If zero or less, don’t file this form . . . . . . . . 9
Do you want to allow an employee, a paid tax preparer, or another person to discuss this return with the IRS? See the
Third- instructions for details. Yes. Complete below. No
Party
Designee Designee’s name and phone number ▶
▶
Select a 5-digit personal identification number (PIN) to use when talking to the IRS ▶
Under penalties of perjury, I declare that I have examined this form, including any accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Sign
▲
Your signature Date Printed title

Here
Printed name Best daytime phone
Print/Type preparer’s name Preparer’s signature Date PTIN
Paid Check if
self-employed
Preparer
Firm’s name ▶ Firm’s EIN ▶
Use Only Firm’s address ▶ Phone no.
How
Fax your completed form to 855-248-0552.
To File
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 56392D Form 7200 (Rev. 4-2021)

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Form 7200

(Rev. April 2021)

Trade name (if any) Applicable calendar quarter in 2021

Part I Tell Us About Your Employment Tax Return

Your signature Date Printed title

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