Federal Statement of Payments Received

Statement of Payments Received
Form 4669 (Rev. 12-2014)
Form

4669

Department of the Treasury - Internal Revenue Service

OMB Number
1545-0364

Statement of Payments Received

(December 2014)

Part 1 - Tell us about the payments that were made (To be completed by payor)
1. Name and address of payee

2. Payee's Taxpayer Identification Number

3. Calendar year

4. Name and address of payor

5. Payor's Taxpayer Identification Number

6. Amount of payments
a. Payments subject to Income Tax Withholding

$

b. Payments subject to Backup Withholding

$

c. Payments to Foreign Persons subject to Withholding Tax

$

d. Payments subject to Additional Medicare Tax Withholding

$

Part 2 - Tell us where the payments were reported and that the taxes were paid (To be completed by payee)
7. Name(s) and address as shown on the payee's tax return

8. The payments shown above on line 6a, 6b, or 6c are reported on my return and the taxes due have been paid in full as shown on
a. Line
b. Schedule

on my Form

return for tax year

on my Form

return for tax year

9. The payments shown above on line 6d are either
a.

Reported on my return on Line
on Form 8959 attached to my Form 1040 return for tax year
The taxes due on the return have been paid in full.

.

OR
b.

I was not liable for Additional Medicare Tax for tax year
because I filed a joint tax return with my spouse and
did not have total Medicare wages and tips and self-employment income of more than $250,000 or total railroad retirement
(RRTA) compensation of more than $250,000.

Part 3 - Sign here (To be completed by payee)
Under penalties of perjury, I declare that I have examined this form and, to the best of my knowledge and belief it is true, correct, and
complete.
Payee name (print)

Payee title (print)

Payee signature

Catalog Number 41877Z

Best daytime telephone number

Date (MM-DD-YYYY)

www.irs.gov

Form 4669 (Rev. 12-2014)

Page 2

Instructions for Form 4669, Statement of Payments Received
Form 4669, Statement of Payments Received
Section and chapter references are to the Internal Revenue Code
unless otherwise noted.
Form 4669 is subject to review by the IRS.

Line 6a: Enter the amount of payments subject to income tax
withholding.
Line 6b: Enter the amount of payments subject to backup withholding.
Line 6c: Enter the amount of payments made to a foreign person
(individual or entity) subject to withholding tax.

General Information
If a payor withholds less than the correct amount of tax, it is liable for
the correct amount that it was required to withhold.
Section 3402 requires employers to withhold income tax on payments
of wages, including reclassified wages and fringe benefits subject to
federal income tax withholding. Employers are also responsible under
sections 3102 and 3202 for withholding a 0.9% Additional Medicare
Tax from wages or compensation paid to an employee in excess of
$200,000 in a calendar year. For more information on income tax
withholding or Additional Medicare Tax, see Publication 15 (Circular
E), Employer’s Tax Guide, the Instructions for Form 8959, or visit
www.irs.gov.
Under section 3406, in the case of a reportable payment a payor is
required to withhold a tax equal to the applicable percentage of the
reportable payment in certain cases (e.g., if the payee fails to furnish
the payee’s taxpayer identification number in the manner required).
This withholding is referred to as “backup withholding.” For more
information on “backup withholding” see Publication 1281, Backup
Withholding for Missing and Incorrect Name/TIN(s), or visit www.irs.
gov and enter the term “backup withholding” in the search box.

Line 6d: Enter the amount of payments subject to Additional Medicare
Tax withholding.
Instructions for the Payee
Part 1
Review the entries in Part 1 provided by the payor. If any of the
information is incorrect, cross out the incorrect information and enter
the correct information. Ask the payor to correct its records.
Part 2
Any reference to Form 1040 includes any return in the Form 1040
series (e.g., Form 1040, Form 1040NR, Form 1040-SS, Form 1040PR, Form 1040A, 1040EZ, or 1040NR-EZ).
Line 7: Enter the payee’s name(s) and address exactly as it appears
on the payee’s tax return.
For payments subject to income tax withholding, payments subject to
backup withholding, or payments to a foreign person (individual or
entity) subject to withholding tax, complete either line 8a or 8b as
appropriate.

Payors may also be required to withhold tax on certain payments
made to a foreign person (individual or entity) subject to withholding
tax under chapters 3 and 4. For more information see Publication
515, Withholding of Tax on Nonresident Aliens and Foreign Entities.

Lines 8a and 8b: Specify the form on which the payments were
reported and the line or schedule of the return. Enter
the tax year of the return.

Purpose of form

For payments subject to Additional Medicare Tax, complete either 9a
or 9b, as appropriate.

A payor who fails to withhold the required tax from a payee, may be
entitled to relief, under sections 3402(d), 3102(f)(3), 1463 or
Regulations section 1.1474-4, if the payor can show that the payee
reported the payments and paid the corresponding tax. Form 4669 is
used by a payor to show that it is entitled to such relief.

Line 9a: Check the box in line 9a if the payee reported the payments
on Form 8959, attached to Form 1040. Specify the line on
Form 8959 on which the payments were reported. Enter the
tax year of the return.

A separate, completed Form 4669 must be obtained by the payor
from each payee for each year relief is requested. After the payor
obtains Forms 4669 for a specific year, the Form 4670, Request for
Relief from Payment of Withholding Tax, is used to transmit the
Forms 4669 for each tax year. A payor should retain a copy of this
information for its files.

Line 9b: Check the box in line 9b if the payee filed using married filing
jointly status on Form 1040 and did not have total Medicare
wages and tips and self-employment income of more than
$250,000 or total railroad retirement (RRTA) compensation
of more than $250,000. The payee was not liable for
Additional Medicare Tax.

Specific Instructions

Part 3. Payee Signature

Instructions for the Payor

The payee must sign the Form 4669 under penalties of perjury. Be
sure to date Form 4669, and print the payee’s name and title (if
applicable). Providing a daytime phone number may help speed
processing. Return the signed form to the payor.

Part 1
Line 1: Enter the payee’s name and address in the space provided.
Line 2: Enter the payee’s taxpayer identification number. This is a
social security number (SSN), an employer identification
number, or an individual taxpayer identification number (ITIN).
Line 3: Enter the calendar year in which the payor made the
payments.
Line 4: Enter the payor’s name and address in the space provided.
Generally, enter the business (legal) name used when the
payor applied for an EIN on Form SS-4, Application for
Employer Identification Number.
Line 5: Enter the payor’s Employer Identification Number. Do not use
the payor’s SSN or ITIN.
Catalog Number 41877Z

www.irs.gov

Form 4669 (Rev. 12-2014)

Page 3

Privacy Act and Paperwork Reduction Act Notice
We ask for the information on this form to carry out the Internal Revenue laws of the United States. Subtitle C, Employment Taxes, of the
Internal Revenue Code requires tax withholding on wages and railroad retirement (RRTA) compensation. Additionally, section 3406 requires
backup withholding on certain payments, and chapters 3 and 4 require tax withholding on certain payments to foreign persons. This form is
used to determine whether the payor is eligible for relief from payment of tax withholding based on payments made to you. You are not required
to provide this information to the payor. Not providing this information, or providing incomplete information, may delay or prevent the payor’s
request for relief. If you choose to provide this information, providing false or fraudulent information may subject you to penalties.
Generally, tax returns and return information are confidential, as required by section 6103. However, section 6103 allows or requires the IRS to
disclose or give the information to others as described in the Code. We may disclose your tax information to the Department of Justice for civil
and criminal litigation, and to cities, states, the District of Columbia, and U.S. commonwealths and possessions to administer their tax laws. We
may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or
to federal law enforcement and intelligence agencies to combat terrorism.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a
valid OMB control number. Books or records relating to a form or instructions must be retained as long as their contents may become material
in the administration of any Internal Revenue law. The time needed to complete and file this form will vary depending on individual
circumstances. The estimated burden for individual taxpayers filing this form is approved under OMB control number 1545-0364 and is included
in the estimates shown in the instructions for their individual income tax return. The estimated burden for all other taxpayers who file this form is
shown below.
Recordkeeping: 5 min.
Learning about the law or the form: 4 min.
Preparing the form: 4 min.
Copying, assembling, and sending the form: 2 min.
If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear
from you. You can send your comments to www.irs.gov/formspubs Click on “More Information” and then click on “Give us feedback on forms
and publications”. Or you can send your comments to Internal Revenue Service, Tax Forms and Publications Division, 1111 Constitution Ave.
NW, IR-6526, Washington, DC 20224. Do not send Form 4669 to this address. Instead, give Form 4669 to the payor.

Catalog Number 41877Z

www.irs.gov

Form 4669 (Rev. 12-2014)