Catalog Number 41877Z www.irs.gov
4669 (Rev. 12-2014)
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.
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
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.
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.
Purpose of form
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.
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.
Instructions for the Payor
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
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.
Line 6a: Enter the amount of payments subject to income tax
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.
Line 6d: Enter the amount of payments subject to Additional Medicare
Instructions for the Payee
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.
Any reference to Form 1040 includes any return in the Form 1040
series (e.g., Form 1040, Form 1040NR, Form 1040-SS, Form 1040-
PR, 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
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.
For payments subject to Additional Medicare Tax, complete either 9a
or 9b, as appropriate.
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.
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.
Part 3. Payee Signature
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.