Court filing
Exhibit B — Alliance Hospice Care, LLC v. United States (Dkt. 1-3, Fed. Cl.)
Summary
Exhibit B to the complaint in Alliance Hospice Care, LLC v. United States, No. 1:24-cv-01547, filed October 1, 2024 in the United States Court of Federal Claims as Document 1-3, is an IRS Form 941-X for Alliance Hospice Care LLC correcting the fourth quarter of 2020. The form enters $5,844.41 as the nonrefundable portion of the employee retention credit on line 18a and also reports a refundable portion of the credit on line 26a. Its line 43 explanation reads FFCRA/CARES ADJUSTMENTS. The paid-preparer block names Malak Tehfe of VRA Accounting Services, LLC, dated June 30, 2023.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
Filed October 1, 2024 in Alliance Hospice Care, LLC v. United States; one of 9 filings from this case.
Record facts
| Court | U.S. Court of Federal Claims |
|---|---|
| Filed | 2024-10-01 |
Cite this document
“Exhibit B — Alliance Hospice Care, LLC v. United States (Dkt. 1-3, Fed. Cl.).”
U.S. Court of Federal Claims, No. 1:24-cv-01547, Doc. 1-3, filed 2024-10-01. Archived at Pandemic Darlings, https://pandemicdarlings.com/court-filings/alliance-hospice-care-llc-v-united-states-of-america/2024-10-01-exhibit-3-to-dkt-1/
, SHA-256 3b4c1de77b668d8215e1925e423e27d3fc4adeb244714c380433cf14764905c5.Full text
Case 1:24-cv-01547-EMR Document 1-3 Filed 10/01/24 Page 1 of 5 EXHIBIT
Form 941-X; Adjusted Employer's QUARTERLY Federal Tax Return or Claim fo^
(Rev. April 2022) Department of the Treasury — Internal Revenue Service
B
1
Employer identification number
(EIN) 4 6 5 7 5 0 2 9
Check the type of return you're correcting.
Name (not your trade name) ALLIANCE HOSPICE CARE LLC
Trade name (if any)
Check the ONE quarter you're correcting.
Address 36 JACONNET STREET SUITE 105
Number Suite or room number
1: January, February, March
NEWTON MA 02461 Q 2: April, May, June
City State ZIP code
3: July, August, September
X I 4: October, November, December
Foreign country name Foreign provlnce/county Foreign postal code
Enter the calendar year of the
Read the separate instructions before completing this form. Use this form to correct errors you
quarter you're correcting.
made on Form 941 or 941-SS, Use a separate Form 941-X for each quarter that needs
correction. Type or print within the boxes. You MUST complete all five pages. Don't attach this I 2020 | (YW)
form to Form 941 or 941-S3 unless you're reclassifying workers; see the instructions for line 42.
Select ONLY one process. See page 6 for additional guidance, including information
on how to treat employment tax credits and social security tax deferrals.
D Adjusted employment tax return. Check this box if you underreported tax amounts.
Also check this box if you overreported tax amounts and you would like to use the
adjustment process to correct the errors. You must check this box if you're correcting
both underreported and overreported tax amounts on this form. The amount shown on
line 27, if less than zero, may only be applied as a credit to your Form 941, Form 941 -S3,
or Form 944 for the tax period in which you're filing this form.
2. Claim. Check this box if you overreported tax amounts only and you would like to use
the claim process to ask for a refund or abatement of the amount shown on line 27.
Don't check this box if you're correcting ANY underreported tax amounts on this form.
Complete the certifications.
3. I certify that I've filed or will tile Forms W-2, Wage and Tax Statement, or Forms W-2c, Corrected Wage and Tax Statement,
as required.
Note: If you're correcting underreported tax amounts only, go to Part 3 on page 2 and skip lines 4 and 5. If you're correcting overreported
tax amounts, for purposes of the certifications on lines 4 and 5, Medicare tax doesn't include Additional Medicare Tax. Form 941-X can't be
used to correct overreported amounts of Additional Medicare Tax unless the amounts weren't withheld from employee wages or an
adjustment is being made for the current year.
4. If you checked line 1 because you're adjusting overreported federal income tax, social security tax, Medicare tax, or Additional
Medicare Tax, check all that apply. You must check at least one box.
I certify that:
II a. I repaid or reimbursed each affected employee for the pvercollected federal income tax or Additional Medicare Tax for the current
year and the overcollected social security tax and Medicare tax for current and prior years. For adjustments of employee social
security tax and Medicare tax overcollected in prior years, I have a written statement from each affected employee stating that hs
or she hasn't claimed (or the claim was rejected) and won't claim a refund or credit for the overcollection.
b. The adjustments of social security tax and Medicare tax are for the employer's share only. I couldn't find the affected employees or
each affected employee didn't give me a written statement that he or she hasn't claimed (or the claim was rejected) and won't
claim a refund or credit for the overcollection.
c- The adjustment is for federal income tax, social security tax, Medicare tax, or Additional Medicare Tax that I didn't withhold from
employee Wages.
5. If you checked line 2 because you're claiming a refund or abatement of overreported federal income tax, social security tax,
Medicare tax, or Additional Medicare Tax, check all that apply. You must check at least one box.
I certify that:
a. I repaid or reimbursed each affected employee for the overcoltected social security tax and Medicare tax. For claims of employee
social security tax and Medicare tax overcollected in prior years, I have a written statement from each affected employee stating
that he or she hasn't claimed (or the claim was rejected) and won't claim a refund or credit for the overcollection.
b. I have a written consent from each affected employee staling that I may file this claim for the employee's share of social security
tax and Medicare tax. For refunds of employee social security tax and Medicare tax overcollected in prior years, I also have a
written statement from each affected employee stating that he or she hasn t claimed (or the claim was rejected) and won't claim a
refund or credit for the overcollection.
c. The claim for social security tax and Medicare tax is for the employer's share only. I couldn't find the affected employees, or each
affected employee didn't give me a written consent to file a claim for the employee's share of social security tax and Medicare tax,
or each affected employee didn't give me a written statement that he or she hasn t claimed (or the claim was rejected) and won't
claim a refund or credit for the overcollection.
X| d- The claim is for federal income tax, social security tax, Medicare tax, or Additional Medicare Tax that I didn't withhold from
employee wages.
For Paperwork Reduction Act Notice, see the separate instructions. www.irs.gov/Form941X Cat.No.17025J Form 941 -X (Rev. 4-2022)
Case 1:24-cv-01547-EMR Document 1-3 Filed 10/01/24 Page 2 of 5
Name (not your trade name) Employer identification number (EIN) Correcting quarter 4 (1,2, 3, 4)
CorrecUng calendar year (YYYY)
ALLIANCE HOSPICE CARE LLC 4 6 _5 750291 2020
Enter the corrections for this quarter. If any line doesn't apply, leave it blank.
Column 1 Column 2 Column 3 Column 4
Total corrected Amount originally Difference
amount (for ALL reported or as (If this amount is a
employees) previously corrected _ negative number, Tax correction
(for ALL employees) ~~ use a minus sign.)
6. Wages, tips, and other Use the amount in Column 1 when you
compensation (Form 941, line 2) prepare your Forms W-2 or Forms W-2c.
7. Federal income tax withheld Copy Column
from wages, tips, and other 3 here .
compensation (Form 941, line 3)
8. Taxable social security wages
(Form 941 or 941-SS, line 5a, x 0.124*=
Column 1)
* If you're correcting your employer share only, use 0.062. See instructions.
9. Qualified sick leave wages*
(Form 941 or 941-SS, line 5a(i), x 0.062=
Column 1)
* Use lins 9 only for qualified sick leave wages paid aftsr March 31, 2020, for leave taken before April 1, 2021.
10. Qualified family leave wages*
(Form 941 or 941-SS, line 5a(ii), x 0.062=
Column 1)
* Use line 10 only for qualified family leave wages paid after March 31 , 2020, for leave taken before April 1,2021.
11. Taxable social security tips (Form
941 or 941-SS, line 5b, Column 1) x 0.124*=
f If you're correcting your employer share only, use 0.062. See instructions.
12. Taxable Medicare wages & tips (Form
941 or 941-SS, line 5c, Column 1) x 0.029*=
* If you're correcting your employer share only, use 0.01 45. See instructions.
13. Taxable wages & tips subject to
Additional Medicare Tax x 0.009*=
withholding (Form 941 or
T Certain wages and tips reported in Column 3 shouldn't be multiplied by 0.009. See Instructions.
941-SS, line 5d)
14. Section 3121 (q) Notice and Copy Column
Demand—Tax due on 3 here . .
unreported -tips (Form 941 or
941-SS, line 5f)
15. Tax adjustments (Form 941 or Copy Column
941-SS, lines 7 through 9) 3 here .
16. Qualified small business payroll tax See
credit for increasing research instructions
activities (Form 941 or 941-SS, line
11 a; you must attach Form 8974)
17. Nonrefundable portion of credit See
for qualified sick and family instructions
leave wages for leave taken
before April 1, 2021 (Form 941
or 941-S3, line 1-I b)
18a. Nonrefundable portion of
employee retention credit* 5844.41 = [ 5844.41 See
Instructions
- 5844.411
* Use line 18a only for corrections to quarters beginning after March 31,2020, and before January 1,2022.
1 Sb. Nonrefundable portion of credit for
See
qualified sick and family leave instructions
wages for leave taken after March
31,2021, and before October 1,
2021 (Form 941 or 94-1-SS, line 11 d)
18c. Nonrefundable portion of COBRA
See
Dremium assistance credit instructions
(Form 941 or 941-SS, line 11 s)
18d. Number of individuals provided
COBRA premium assistance
(Form 941 or 941-SS, line Hf)
19. Special addition to wages for See
federal income tax Instructions
20. Special addition to wages for See
social security taxes Instructions
21. Special addition to wages for See
Medicare taxes instructions
Page 2 Form 941 -X (Rev. 4-2022)
Case 1:24-cv-01547-EMR Document 1-3 Filed 10/01/24 Page 3 of 5
Name (not your trade name) Employer Identification number (EIN) Correcting quarter 4 (1,2, 3, 4)
Correcting calendar year (YYYY)
ALLIANCE HOSPICE CARE LLC 4 6 _5 750291 2020
Enter the corrections for this quarter. If any line doesn't apply, leave it blank, (continued)
Column 1 Column 2 Column 3 Column 4
Total corrected Amount originally Difference
amount (for ALL reported or as (If this amount is a Tax correction
employees) previously corrected negative number,
(forALL employees) use a minus sign.)
22. Special addition to wages for See
Additional Medicare Tax instructions
23. Combine the amounts on lines 7 through 22 of Column 4 5844.43J
24. Deferred amount of social
See
security tax* (Form 941 or Instructions
941-SS, line 13b) * Use this line to correct the employer deferral for the second quarter of 2020 and the employer and employee defen-31 for the third and fourth quarters of 2020.
25. Refundable oortion of credit for Sea
qualified sick and family leave Instructions
wages for leave taken before
April 1,2021 (Form 941 or 941-
SS, line 13c)
26a. Refundable portion of employee
retention credit* (Form 941 or 22046.Ocj 22046.Oc| instructions -22046.OS)
941-SS, line 13d) • Use line 26a only for corrections to quarters beginning after March 31,2020, and before January 1, 2022.
26b. Refundable portion of credit for
See
qualified sick and family laave instructions
wages for leave taken after March
31, 2021, and before October 1,
2021 (Form 941 or 941-S3, line 13e)
26c. Refundable portion of COBRA See
premium assistance credit Instructions
(Form 941 or941-SS, line 13f)
27. Total. Combine the amounts on lines 23 through 26c of Column 4 -27890,5C)
If line 27 is less than zero;
• If you checked line 1, this is the amount youwant applied as a credit to your Form 941 or 941 -SS for the tax period in which you're
filing this form. (If you're currently filing a Form 944, Employer's ANNUAL Federal Tax Return, see the instructions.)
• If you checked line 2, this is the amount you want refunded or abated.
If line 27 is more than zero, this is the amount you owe. Pay this amount by the time you file this return. For information on how to
pay, see Amount you owe in the instructions.
28. Qualified health plan expenses
allocable to qualified sick leave
wages for leave taken before
April 1, 2021 (Form 941 or 941-
SS, line 19)
29. Qualified health plan expenses
allocableto qualified family
leave wages for leave taken
before April 1, 2021 (Form 941 or
941-S3, line 20)
30. Qualified wages for the
employee retention credit*
55781.OCJ 55781.00|
(Form 941 or941-SS, line 21) " Use line 30 only for coireclions to quarters beginning after March 31, 2020, and before January 1,2022.
31 a. Qualified health plan expenses for
the employee retention credit*
(Form 941 or 941-SS, line 22) ^ Use Hne 31a only for corrections to quarters beginning after March 31,2020, and before January 1,2022.
31 b. Check here if you're eligible for the employee retention credit in the third or fourth quarter of 2021
solely because your business is a recovery startup business . . . . . . . . . . . , ||
32. Credit from Form 5884-C, line
11, for this quarter* (Form 941 or
941-SS, line 23) * Use line 32 only for corrections to quarters beginning after March 31, 2020, and before April 1, 2021.
Page 3 Form 941 -X (Rev. 4-2022)
Case 1:24-cv-01547-EMR Document 1-3 Filed 10/01/24 Page 4 of 5
Name (not your trade name) Employer identification number (EIN) Correcting quarter 4 (1 , 2, 3, 4)
Correcting calendar year ffYYY)
ALLIANCE HOSPICE CARE LLC 4 6-575 029 1 2020
\usnv:fu Enter the corrections for this quarter. If any line doesn't apply, leave it blank, (continued)
Column 1 Column 2 Column 3
Total corrected Amount originally Difference
amount (for ALL reported or as (If Ms amount is a
employees) previously corrected _ negative number,
(for ALL employees) use a minus sign.)
33a. Qualified wages paid March 13
through March 31, 2020, for the
employee retention credit* • Use line 33a only for corrections to the second quarter of 2020.
(Form 941 or 941-SS, line 24)
33b. Deferred amount of the
employee share of social
security tax included on Form • Use line 33b only for corrections to the third and fourth quarters of 2020.
941 or941-SS,line13b*
(Form 941 or 941-SS, line 24)
34. Qualified health plan expenses
allocable to wages reported on
Form 941 or 941-SS, line 24* ' Use Una 34 only for corrections to the second quarter of 2020.
(Form 941 or 941-SS, line 25)
Caution: Lines 35-40 apply only to quarters beginning after March 31,2021.
35. Qualified sick leave wages for
leave taken after March 31, 2021,
and before October 1,2021 (Form
941 or 941-SS, line 23)
36. Qualified health plan expenses
allocable to qualified sick leave
wages for leave taken after March
31,2021, and before October 1,
2021 (Form 941 or 941-SS, line 24)
37. Amounts under certain collectively
bargained agreements allocableto
qualified sick leave wages for leave
taken after March 31,2021, and
before October 1,2021 (Form 941 or
941-SS, line 25)
38. Qualified family leave wages for
leave taken after March 31, 2021,
and before October 1,2021 (Form
941 or 941-SS, line 26)
39. Qualified health plan expenses
allocable to qualified family leave
wages for leave taken after March
31,2021, and before October 1,
2021 (Form 941 or 941-SS, line 27)
40. Amounts under certain collectively
bargained agreements allocableto
qualified family leave wages
for leave taken after March 31,
2021, and before October 1, 2021
(Form 941 or 941 - SS, line 28)
Page 4 Form 941 -X (Rev. 4-2022)
Case 1:24-cv-01547-EMR Document 1-3 Filed 10/01/24 Page 5 of 5
Name (not your trade name) Employer identification number (EIN) Correcting quarter 4 (1,2, 3, 4)
Correcting calendar year fr'YYY)
ALLIANCE HOSPICE CARE LLC 4 6-5750291 2020
Explain your corrections for this quarter.
41. Check here if any corrections you entered on a line include both underreported and overreported amounts. Explain both
your underreported and overreported amounts on line 43.
42. Check here if any corrections involve reclassified workers. Explain on line 43.
43. You must give us a detailed explanation of how you determined your corrections. See the instructions.
FFCRA/CARES ADJUSTMENTS
Sign here. You must complete all five pages of this form and sign it.
Under penalties of perjury, I declare that I have filed an original Form 941 or Form 941 -SS and that I have examined this adjusted return or claim, including
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.
Print your
name here Olga Vaserman
Sign your
name here Print your
title here Member
Date \Oji07/W^^ Best daytime phone
Check if you're self-employed . . .
Paid Preparer Use Only
Preparer's name Malak Tehfe PTIN P03064423
Preparer's signature ~mm Date 06/30/2023
lalak i enre (jun -su, Luu iu:/-i bu i)
Firm's name (or yours
if self-employed) |VRA Accounting Services, LLC EIN 82-1533719
Address 30095 Northwestern Hwy, Ste 102 Phone 248-605-3000
City 'Farmington Hills State Ml ZIP code 48334-3285
Page 5 Form 941 -X (Rev. 4-2022)File and source
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- Original
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