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Official form guide
Form 4669: Statement of Payments Received
Internal Revenue Service Form 4669 is a Statement of Payments Received used by a payor to show entitlement to tax relief if they failed to withhold required tax. Employers are responsible 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.
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IRS Form 4669 - Statement of Payments Received
Internal Revenue Service Form 4669 is a Statement of Payments Received used by a payor to show entitlement to tax relief if they failed to withhold required tax. Employers are responsible 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.
Risk Radar
Scan points- 1A separate, completed Form 4669 must be obtained by the payor from each payee for each year relief is requested.
- 2Entering the payor’s Social Security Number or ITIN instead of the required Employer Identification Number (Line 5).
- 3Failing to obtain a separate, completed Form 4669 for every payee and for each tax year relief is requested.
- 4Not entering the payee's name and address exactly as it appears on the payee’s tax return (Line 7).
- 5Completing Part 2 without specifying the form or line of the return where payments were reported.
Plain English
This form helps a payor prove that they were supposed to withhold taxes but did not. The payee uses this documentation, along with Form 4670, to request relief from the IRS if the required tax was not withheld correctly. A separate, completed Form 4669 must be obtained by the payor from each payee for each year relief is requested.
Submission Date
- Filing date: 2014-12-18 00:00:00
- Preparation window: collect IDs, supporting records, and signatures in advance.
- Final review: verify names, dates, and required fields before submission.
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What this form is for
- Use this form when a payor needs to show that it is entitled to tax relief under sections 3402(d), 3102(f)(3), 1463, or Regulations section 1.1474-4 because the payor failed to withhold required tax.
- Do not use this form when filing a complete income tax return; the payee must report payments on their Form 1040 series return instead.
- Check Form 4670 instead when transmitting multiple Forms 4669 for different tax years.
Form selector
Use this form or another form?
The payee must report payments on the return using Form 8959 attached to Form 1040 for Additional Medicare Tax reporting
The box in line 9a is checked if the payee reported the payments on this specific form.
✓ Confirm that the tax year entered matches the filing year.
To request relief from payment of withholding tax, a payor must first obtain a separate, completed Form 4669 for each payee and year before submitting Form 4670
The payor uses this form to transmit multiple Forms 4669 when requesting relief.
✓ Retain copies of the submitted Forms 4669 and Form 4670.
If a payor needs to enter their business name, they should generally use the legal name provided when applying for an EIN on Form SS-4
Line 4 requires the payor's legal name, which is typically found on this form.
✓ Verify that the name entered matches the official record used by the IRS.
The payee must complete Part 3 and sign Form 4669 under penalties of perjury to declare the information as true, correct, and complete
This signature validates the accuracy of the payments reported on the form.
✓ Ensure the signer is the individual or entity receiving the payment.
Deadline or filing window
Not stated in the official source.
Checklist
What you need before filling it out
Payee's name, address, and TIN (Part 1)
Payee must provide this information · Part 1 of Form 4669
Payor's EIN and details (Part 1)
Payor must enter its legal business name and Employer Identification Number (EIN). · Part 1 of Form 4669
Reported payments amounts (Line 6a-6d)
The payor must accurately enter all specific payment amounts, including those for Additional Medicare Tax Withholding. · Part 1 of Form 4669
Tax reporting details (Part 2)
Payee must specify which form and line (e.g., Form 1040, Line X) reported the payments. · Part 2 of Form 4669
Before you submit
- 1The payee must ensure they have completed Part 3 by signing Form 4669 under penalties of perjury.
- 2Part 1 requires the payor to enter the name and address of the payee (Line 1) and the payee's Taxpayer Identification Number (Line 2).
- 3The payor must fill out Line 6a, 6b, 6c, and 6d by entering the specific amounts for payments subject to various types of withholding.
- 4For Part 1, the payor must enter their own name and address on Line 4 and their Employer Identification Number (Line 5).
- 5The payee must specify the form, line, or schedule where the payments were reported and enter the correct tax year in Part 2. Line 7.
- 6If reporting Additional Medicare Tax (Line 6d), the payee must check either box 9a (Form 8959) or box 9b (Joint filing status).
- 7The payor should use the current edition of Form 4669, noting that the form revision date is 12-2014.
How to file this form
- 1Complete Part 1: The payor must enter the payee’s name/address (Line 1), TIN (Line 2), calendar year (Line 3), and both the payor’s name/address (Line 4) and EIN (Line 5).
- 2Complete Part 1: The payor must calculate and enter the specific amounts of payments subject to various withholdings on Line 6a through Line 6d.
- 3Complete Part 2: The payee reviews the data in Part 1, then enters their name/address (Line 7) and specifies exactly where the payment was reported on their tax return or Form 8959 (Lines 8 and 9).
- 4Execute Part 3: The payee signs the form under penalties of perjury, providing all required identifying information.
Known limitations
- 1A separate, completed Form 4669 must be obtained by the payor from each payee for every year relief is requested.
- 2The form determines whether a payor is eligible for relief from payment of tax withholding based on payments made to the payee.
- 3Payees are not required to provide this information to the payor.
Field map
Compact field-by-field guide
General Info
2 items
Full legal name and taxpayer identification number (SSN or EIN).
Current mailing address.
Details
2 items
Complete all applicable sections of this form according to the official IRS instructions.
Enter the relevant dollar amount if this form involves tax calculation.
Certification
1 items
Read and acknowledge any certifications required by this form.
Signatures
1 items
Sign and date. Unsigned forms cannot be processed.
Almost done reviewing the fields?
Fillable formOpen in Editor->The current edition of IRS Form 4669 is the December 2014 revision (Rev. 12-2014). The official source does not point to a page containing later revisions or updated information.
What changed or needs a fresh check
- Edition date — confirm the revision date reads 12-2014.
- Form number — verify the form is labeled Form 4669.
- Required documents — ensure that if Additional Medicare Tax applies, both Form 8959 and Form 1040 are available for reference.
- Submission destination — do not send Form 4669 to Internal Revenue Service, Tax Forms and Publications Division; instead, give the form to the payor.
Quick Facts
Downloads
After you file
- 1A payor should retain a copy of the completed Forms 4669 and Form 4670 for its files.
- 2The payee must keep a copy of the signed Form 4669, as this document proves that payments were reported and taxes were paid.
- 3If filing is required due to withholding failure, the payor may use Form 4669 to show entitlement to relief under specific sections (e.g., 3402(d)).
- 4The payee should consult Publication 15 or visit www.irs.gov for more information regarding income tax withholding or Additional Medicare Tax.
Sources
- SRCForm p.1 — Line 1 requires the payee’s name and address to be entered by the payor.
- SRCForm p.2 — Employers are 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.
- SRCForm p.2 — Payors may 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.
- SRCForm p.2 — The payor must enter the payor’s Employer Identification Number on Line 5, generally using the business name applied for an EIN on Form SS-4.
- SRCForm p.2 — After obtaining 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.
- SRCForm p.3 — Payors should give Form 4669 to the payor and not send it to Internal Revenue Service, Tax Forms and Publications Division, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224.
Common confusion points
Should I enter my SSN on Form 4669?
Line 2 requires the payee's Taxpayer Identification Number (TIN), which can be an SSN, EIN, or ITIN.
→ Do not use your SSN if you are required to provide an Employer Identification Number.
Who fills out Part 1 and who fills out Part 2?
Part 1 is completed by the payor (the entity making the payments), while Part 2 is completed by the payee (the recipient of the payments).
→ The payor must fill in payment amounts, and the payee must confirm where those amounts were reported.
What is the difference between Line 6a and Line 6b?
Line 6a covers general payments subject to Income Tax Withholding, while Line 6b covers payments subject to Backup Withholding.
→ Ensure you categorize the payment amount correctly based on which type of withholding applies.
If I filed jointly with my spouse, do I still need to complete Part 2?
Yes; if filing jointly and not meeting the specified income thresholds, the payee must check box 9b in Part 2.
→ Check box 9b only if you meet the criteria for exemption from Additional Medicare Tax.
Can I use my SSN on Line 5 when filling out Form 4669?
No; Line 5 requires the payor's Employer Identification Number (EIN).
→ The source specifically instructs that the payor should not use their SSN or ITIN for this line.
Workflow map
Related forms and next steps
Before
Current
After
Often used with
⚠ If something goes wrong
- Publication 1281 — This publication provides information regarding Backup Withholding for Missing and Incorrect Name/TIN(s).
Questions about IRS Form 4669
What is IRS Form 4669 used for?
This form helps a payor prove that they were supposed to withhold taxes but did not. The payee uses this documentation, along with Form 4670, to request relief from the IRS if the required tax was not withheld correctly. A separate, completed Form 4669 must be obtained by the payor from each payee for each year relief is requested.
Who must file IRS Form 4669?
The payor completes Part 1 with payment details; the payee reviews these entries in Part 1 and completes Part 2 to report where payments were reported and that taxes were paid.
What information does IRS Form 4669 require?
Part 1 collects the payee's name and address (Line 1), the payor's business legal name, and the payor’s Employer Identification Number (EIN) (Line 5). Part 2 requires the payee to list their name(s) and address exactly as shown on their tax return (Line 7).
Where do I file IRS Form 4669?
Do not send Form 4669 to the mailing address listed; instead, give Form 4669 to the payor.
How do I complete IRS Form 4669?
The payor completes Part 1 by entering payment details and identifying numbers. The payee reviews these entries in Part 1, correcting them if necessary, then completes Part 2. Finally, the payee must sign the Form 4669 under penalties of perjury (Part 3).
What happens if IRS Form 4669 is filed incorrectly?
If a payor withholds less than the correct amount of tax, it is liable for the correct amount that it was required to withhold.
Should I enter my SSN on Form 4669?
Line 2 requires the payee's Taxpayer Identification Number (TIN), which can be an SSN, EIN, or ITIN. Do not use your SSN if you are required to provide an Employer Identification Number.
Who fills out Part 1 and who fills out Part 2?
Part 1 is completed by the payor (the entity making the payments), while Part 2 is completed by the payee (the recipient of the payments). The payor must fill in payment amounts, and the payee must confirm where those amounts were reported.
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