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Ly Tax Return for Household Employees 4141 Form (Rev. November 1994) OMB No. 1545-0034 (For Social Security, Medicare, and Withheld Income Taxes) See separate Instructions. Name Date quarter ended Address and ZIP code Employer identification number FOR IRS USE ONLY If address is different from prior return, check here. 1 1 1 1 1 4 4 4 5 6 1 1 1 1 1 7 7 7 7 2 2 2 2 2 2 8 8 8 9 2 2 2 10 10 3 3 3 3 3 3 10 10 10 10 10 10 10 7 7 1.

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