Fillable Form 4669 (2014)

What is Form 4669?

Form 4669, Statement of Payments Received, is a recorded document with the IRS that reflects all payments received on which income taxes, FICA taxes, or other taxes were not withheld. The form includes spaces to list the amount of the payments, as well as the names of the payer and the payee. Form 4669 declares all taxes were paid.

Form 4669 also essentially functions as an affidavit of unchained status used to validate user data in previous years. A payor who withholds less than the minimum or correct amount of tax is liable for the amount of tax to withhold as required.

What is the purpose of Form 4669?

Form 4669 is used to show that the payor is entitled to relief. A payor may be entitled to relief under sections 3402(d), 3102(f)(3), 146, or Regulations sections 1.1474-4 when it misses to withhold the required tax from a payee if the payor has proof that the payee reported and paid the corresponding tax.

The payor shall obtain a separate, completed Form 4669 from each payee for each year that relief is requested. Form 4670, Request for Relief from Payment of Withholding Tax, is used to transmit the 4669 forms for each year after the payor obtained the said form. The payor should keep a copy of the information for its files for future references.

How to fill out Form 4669?

The time needed to complete and file this form varies on individual circumstances.

PART 1 - TELL US ABOUT THE PAYMENTS THAT WERE MADE

This should be completed by the payor only.

Line 1. Name and Address of the Payee

Enter the full name of the payee.

Then enter the address of the payee in this format: street number, street name, apartment or suite number (if there’s any), city, state, and ZIP code.

Line 2. Payee’s Taxpayer Identification Number

Enter the payee’s tax identification number (TIN). This is also a social security number (SSN), an employer identification number, or an individual taxpayer identification number (ITIN).

Line 3. Calendar Year

Enter the calendar year when the payor made the payments.

Line 4. Name and Address of Payor

Enter the full name of the payor. This should be the business or legal name of the payor that is indicated in his or her EIN application using Form SS-4, Application for Employer Identification Number.

Then enter the address of the payor in this format: street number, street name, apartment or suite number (if there’s any), city, state, and ZIP code.

Line 5. Payor’s Tax Identification Number

Enter the payor’s Employer Identification number.

Note: Do not provide the payor’s SSN or ITIN.

Line 6. Amount of Payments

Line 6a. Payments subject to Income Tax Withholding

Enter the amount of payments subject to income tax withholding.

Line 6b. Payments subject to Backup Withholding

Enter the amount of payments subject to backup withholding.

Line 6c. Payments to Foreign Persons subject to Withholding Tax.

Enter the amount of payments made to a foreign person, which could be an individual or entity, subject to withholding tax.

Line 6d. Payments to Additional Medicare Tax Withholding

Enter the amount of payments subject to additional medicare tax withholding.

PART 2 - TELL US WHERE THE PAYMENTS WERE REPORTED AND THAT THE TAXES WERE PAID

This should be completed by the payee only.

Line 7. Name(s) and address as shown on the payee’s tax return.

Enter the full name of the payee.

Enter the exact address as it appears on the payee’s tax return.

Line 8.

Complete either Line 8a or Line 8b 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.

Line 8a: Specify the line number and form in which the payments were transacted. Then, enter the tax year of the return.

Line 8b: Specify the schedule type and form in which the payments were transacted. Then, enter the tax year of the return.

Line 9.

Complete either Line 9a or Line 9b for payments subject to Additional Medicare Tax.

Line 9a: Mark the box in Line 9a if the payee reported the payments on Form 8959 that is attached to Form 1040.

Enter the line number on Form 8959 in which the payments were reported.

Then, enter the tax year of the year.

Line 9b: Mark 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 or more than $250,000. The payee was not liable for Additional Medicare Tax and then enter the tax year.

PART 3 - SIGN HERE

This should be completed by the payee only.

Review and check the information provided in this form to avoid legal consequences under the penalties of perjury. Signing confirms that all information in this form is true and correct.

Payee Name

Enter the full name of the payee.

Payee Title

Enter the title of the payee if there’s any.

Best Daytime Telephone Number

Enter your active phone number and this may help speed up the processing of this form.

Payee Signature

Enter your signature.

Date

Enter the date when you sign this form. Follow this format: mm/dd/yyyy.

Tips when filing Form 4669

• Review the entries in Part 1 provided by the payor. If there are revisions, cross out the incorrect details and enter the right one. You must also ask the payor to correct the records on file.

• Any reference to Form 1040 includes any return in the Form 1040 series, such as Form 1040, Form 1040NR, Form 1040-SS, Form 1040-PR, Form 1040A, 1040EZ, or 1040NR-EZ.

• You are not obliged to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form shows a valid OMB control number.