Form 941 and Schedule B (Form 941) for PEI STAFFING LLC — Document 30-4, No. 1:23-cr-00210-RDB

Summary

Document 30-4 in Case 1:23-cr-00210-RDB, filed March 19, 2025: Form 941 sections in the name of PEI STAFFING LLC that ask the filer to describe the deposit schedule and tax liability for the quarter, then ask about the business (Part 3) and a third-party designee. It is followed by a Schedule B (Form 941) Report of Tax Liability for Semiweekly Schedule Depositors (Rev. 1-2017). The Schedule B lists tax liability for Month 1 of 158,123.69, Month 2 of 206,582.24 and Month 3 of 160,221.41, and a total liability for the quarter of 524,927.34.

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Case 1:23-cr-00210-RDB Document 30-4 Filed 03/19/25 Page2of3

Name (not your tradename) Employer identification number (EIN)

PEI STAFFING LLC 27-3294970

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

Pe are unsure about whether you are a monthly schedule depositor or a semiweekly schedule depositor, see section 11
of Pub. 15.

16 Check one: L] Line 12 on this return is less than $2,500 or tine 12 on the return for the prior quarter was less than $2,500, and you didn't
incur a $100,000 next-day deposit obligation during the current quarter. If line 12 for the prior quarter was less than $2,500 but
line 12 on this return is $100,000 or more, you must provide a record of your fedral tax liability. If you are a monthly schedule
depositor, complete the deposit schedule below; if you are a semiweekly schedule depositor, attach Schedule B (Form 941). Go to
Part 3.

|} You were a monthly schedule depositor for the entlre quarter. Enter your tax liability for each month and total
liability for the quarter, then go to Part 3.

Tax liability: Month 4 |

Month 2 |

|
|
Month 3 | |
|

Total liabillty for quarter | Total must equal line 12.

[X] You were a semiweekly schedule depositor for any part of this quarter. Complete Schedule B (Form 941),
Report of Tax Liability for Semiweekly Schedule Depositors, and attach it to Form 941.

[Part 3: | Tell us about your business. If a question does NOT apply to your business, leave it blank.

17 If your business has closed or you stopped paying wages [_] Check here, and

enter the final date you paid wages

18 If you are a seasonal employer and you don’t have te fille a return for every quarter of the year ow. [_] Check here.

May we speak with your third-party designee?
Do you want to allow an employee, a pald tax preparer, or another person to discuss this return with the [RS? See the instructions

for details.
[X] Yes. Designee’s name and phone number | LISA HUFF | | 216-831-8900 |
Select a 5-digit Personal Identification Number (PIN) to use when talking to the IRS. 34010 |
LJ No.

Sign here. You MUST complete both pages of Form 941 and SIGN it.

Under penalties of perjury, | declare that | have examined this retum, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Deciaration of preparer (other than taxpayer) is based on ail information of which preparer has any knowledge.

Print your :
Sign your name here | Lisa Huff |

name here i La ededf~ Print your 1 :
* s title here | Fiduc lary |

| 216 831-8900

Date [07-11-2019 Best daytime phone

Paid Preparer Use Only Check if you are self-employed _ .......... [ ]
Preparer’s name | | enn | |
Preparer’s signature | | Date | |
Firm’s name (or yours [ | EIN | |
if self-employed) | J — \ |
Address | | Phone | |
City | State ZiP code | |
Page 2 Form 941 (Rev, 1-2019)

402 18-Jul-2019 10:04 213715 1122
Case 1:23-cr-00210-RDB

Schedule B (Form 941):

Report of Tax Liability for Semiweekly Schedule Depositors

(Rev. January 2017)

Employer identification number

(EIN)

Calendar year

Document 30-4

Department of the Treasury -- Internal Revenue Service

27-3294970
Name (noi yourtradename) PRT STAFFING LLC

2019

(Also check quarter)

Filed 03/19/25

Page 3 of 3

OMB No. 1545-0029

Report for this Quarter ...

[] 1: January, February, March

2: April, May, June

[| 3: July, August, September

LJ 4: October, November, December

Use this schedule to show your TAX LIABILITY for tne quarter; don’t use it 10 show your deposits. When you file this form with Form 941 or
Form 941-88, don't change your tax liability by adjustments reported on any Forms 941-X or 944-X. You must fill out this form and attach it to
Form 941 or Form 941-SS if you’re a semlweekly schedule depositor or became one because your accumulated tax liability on any day was
$100,000 or more. Write your daily tax tiability on the numbered space that corresponds to the date wages were paid. See Section 11 In

Pub. 15 for details.
Month 1

Tax liability for Month 1
158,123.69

Tax liability for Month 2
206,582.24

Tax liability for Month 3
160,221.41

al Jed 39565. 919 _ bos

Month 2

i| Jo! Fr 41983 .38],J |
al | ol lool 129 .12]og 234.64]
a l15| leal 7.62} 43856 .60|

Month 3

Fill in your total liability for the quarter (Month 1+ Month 2+ Month 3) &
Total must equal line 12 on Form 941 or Form 941-SS,

Total liability for the quarter
524,927.34

For Paperwork Reduction Act Notice, see separate instructions.

AQ2 18-Jul-2019 10:04 213715 1122

Schedule B (Form 941) (Rev. 1-2017)


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