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IRSOther IRS Forms (4000–6999)

Official form guide

Form 4669: Statement of Payments Received

Internal Revenue Service Form 4669 is the Statement of Payments Received used by payors to document payments and withholding so they can request relief from tax. It records amounts subject to income, backup, foreign, and Additional Medicare Tax (0.9% on wages over $200,000).

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Form Overview

IRS Form 4669 - Statement of Payments Received

Internal Revenue Service Form 4669 is the Statement of Payments Received used by payors to document payments and withholding so they can request relief from tax. It records amounts subject to income, backup, foreign, and Additional Medicare Tax (0.9% on wages over $200,000).

The form collects the payee’s name, address, and TIN; the calendar year; the payor’s name, address, and EIN; and the amounts of payments subject to income, backup, foreign, and Additional Medicare Tax withholding. The payee then confirms reporting details and signs under penalty of perjury.

Risk Radar

Scan points
  • 1Submitting an incomplete or inaccurate Form 4669 leaves the payor liable for the full tax owed.
  • 2Leaving the payor’s Employer Identification Number blank on line 5.
  • 3Omitting the amount of payments subject to Additional Medicare Tax on line 6d.
  • 4Failing to sign the form under penalties of perjury in Part 3.
  • 5Providing an incorrect payee Taxpayer Identification Number on line 2.

Plain English

Form 4669 lets a payor show the IRS the payments it made and the taxes it withheld. The payor gets a completed copy from each payee and keeps it for its records. The form helps the payor qualify for relief if it under‑withheld tax.

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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Glossary Terms

documentwithheldforeignincome

Hover a term to preview the meaning.

What this form is for

  • Use this form when a payor needs to document payments and withholding to request relief from tax under sections 3402(d), 3102(f)(3), 1463 or regulations.
  • Check Form 4670 instead when you need to transmit the completed Form 4669 to the IRS for relief.

Form selector

Use this form or another form?

Payor seeks relief from withholding tax after obtaining Form 4669

Form 4670 transmits the completed Form 4669 to the IRS for the requested year

✓ Confirm Form 4670 is attached and signed

Form 4670

Payee reports payments subject to Additional Medicare Tax on their return

Form 8959 reports Additional Medicare Tax and must be attached to Form 1040

✓ Verify line 9a on Form 4669 matches the line on Form 8959

Form 8959

Payments are reported on a Form 1040 series return

The payee must indicate the line or schedule on the Form 1040 where payments were reported

✓ Ensure the correct line or schedule number is entered on Form 4669 Part 2

Form 1040

Deadline or filing window

Not stated in the official source.

Checklist

What you need before filling it out

1

Line 1: Payee name and address

Payee’s name and address · Form 4669 Part 1 entry

⚠ Misspelling or incomplete address✕ Low
2

Line 2: Payee TIN

Social Security Number, EIN, or ITIN · Payee records

⚠ Entering SSN instead of EIN for a business payor✕ Medium
3

Line 6a: Payments subject to Income Tax Withholding

Amount of payments · Payor records

⚠ Omitting amounts or rounding errors✕ Medium
4

Line 6d: Payments subject to Additional Medicare Tax withholding

Amount of payments · Payor records

⚠ Forgetting to include Medicare tax✕ High
5

Part 2 Line 7: Payee name and address as on tax return

Payee’s tax return · Payee’s Form 1040 (or other)

⚠ Using a different address than on the tax return✕ Low
6

Part 2 Line 9a: Additional Medicare Tax reported on Form 8959

Form 8959 line number · Form 8959 attached to Form 1040

⚠ Selecting wrong box (9a vs 9b)✕ Medium

Before you submit

  1. 1Review all Part 1 entries for accuracy
  2. 2Verify the payor’s EIN is entered, not the SSN
  3. 3Confirm the amounts in lines 6a‑6d are correct
  4. 4Ensure the payee’s name and address on Part 2 match the tax return
  5. 5Specify the correct line or schedule where payments were reported
  6. 6Select the appropriate box for Additional Medicare Tax (9a or 9b)
  7. 7Obtain the payee’s signature under penalties of perjury
  8. 8Enter the date in MM‑DD‑YYYY format
  9. 9Keep a copy of the completed Form 4669 for your records
  10. 10Deliver the original Form 4669 to the payor (do not mail to the IRS address)

How to file this form

  1. 1Collect the payor’s payment data and the payee’s TIN — retain records as proof
  2. 2Enter the payee’s name, address, TIN, the calendar year, and the payor’s name, address, and EIN in Part 1 — verify entries before proceeding
  3. 3Record the amounts for lines 6a‑6d in Part 1 — keep the completed section as proof
  4. 4Have the payee complete Part 2, specifying the tax return line or schedule and tax year — the signed section serves as proof
  5. 5Obtain the payee’s signature and date on Part 3 under penalties of perjury — the signed form is proof of acknowledgment
  6. 6Give the fully completed Form 4669 to the payor for filing with Form 4670 — the payor’s receipt confirms submission

Known limitations

  1. 1Form 4669 applies only when the payor is requesting relief from withholding tax — it is not used for routine reporting without a relief request.
  2. 2A separate Form 4669 must be obtained for each payee for each tax year — it cannot cover multiple payees or years on one form.
  3. 3The form must be given to the payor, not mailed to the IRS address — sending it to the IRS is not permitted.
  4. 4You are not required to provide the information to the payor — lack of a payee’s response may delay the payor’s relief request.

Field map

Compact field-by-field guide

6 fields

General Info

2 items

Taxpayer Name and TIN

Full legal name and taxpayer identification number (SSN or EIN).

Requiredtext
Address

Current mailing address.

Requiredtext

Details

2 items

Required Information

Complete all applicable sections of this form according to the official IRS instructions.

Requiredtext
Amount (if applicable)

Enter the relevant dollar amount if this form involves tax calculation.

amount

Certification

1 items

Certification Statement

Read and acknowledge any certifications required by this form.

Requiredcheckbox

Signatures

1 items

Signature

Sign and date. Unsigned forms cannot be processed.

Requiredsignature
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Current form status
IRS

The form is the December 2014 revision (Rev. 12‑2014); the source does not indicate a newer edition.

What changed or needs a fresh check

  • Edition date — confirm the revision reads 12‑2014
  • Fee — Not stated in the official source
  • Mailing address — Not stated in the official source
  • Signature — confirm the payee signs under penalties of perjury

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Quick Facts

Payors who are seeking relief from withholding tax must obtain a completed Form 4669 from each payee for the tax year.
The form collects the payee’s name, address, and TIN; the calendar year; the payor’s name, address, and EIN; and the amounts of payments subject to income, backup, foreign, and Additional Medicare Tax withholding. The payee then confirms reporting details and signs under penalty of perjury.
Not stated in the official source.
Do not send Form 4669 to the IRS; instead, give the completed form to the payor.
If the payor withholds less than required, it remains liable for the full tax owed, and false statements expose the signer to penalties of perjury.
The payor completes Part 1 lines 1‑6 with payee and payor information and the payment amounts. The payee reviews Part 1, corrects any errors, and fills Part 2 lines 7‑9 with reporting details. The payee then signs Part 3 under penalty of perjury. The completed form is returned to the payor for its records and for inclusion with Form 4670.

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After you file

  1. 1Retain a copy of the completed Form 4669 in the payor’s files.
  2. 2Give the completed Form 4669 to the payor; do not send it to the IRS address.
  3. 3After collecting Forms 4669 for the year, the payor uses Form 4670 to transmit them to the IRS.
  4. 4Verify that all required fields (payee name, TIN, calendar year, amounts) are filled to avoid delays.
  5. 5If any information is incomplete, provide the missing data promptly to prevent the relief request from being delayed.

Sources

  • SRCForm p.1 — official title is Statement of Payments Received.
  • SRCForm p.1 — Part 1 lists amounts subject to Income Tax Withholding, Backup Withholding, Foreign Persons, and Additional Medicare Tax.
  • SRCForm p.2 — purpose: Form 4669 is used by a payor to show that it is entitled to such relief.
  • SRCForm p.2 — requirement: a separate, completed Form 4669 must be obtained by each payor from each payee for each year relief is requested.
  • SRCForm p.2 — after obtaining Forms 4669, Form 4670, Request for Relief from Payment of Withholding Tax, is used to transmit the Forms 4669 for each tax year.
  • SRCForm p.2 — retention: a payor should retain a copy of this information for its files.
  • SRCForm p.3 — do not send Form 4669 to the IRS address; instead, give Form 4669 to the payor.
  • SRCForm p.3 — you are not required to provide this information to the payor.
  • SRCForm p.2 — employers must withhold a 0.9% Additional Medicare Tax from wages in excess of $200,000 in a calendar year.
  • SRCForm p.2 — under section 3406, a payor must withhold backup withholding when the payee fails to furnish the required TIN.

Common confusion points

Do I send Form 4669 to the IRS?

The address on the form is for comments only, not for filing.

→ Confirm you are delivering the form directly to the payor.

Am I required to fill out Form 4669 as the payee?

The form is primarily for the payor to request relief; the payee’s participation is optional.

→ Check whether you are acting as the payor; if you are the payee, you may choose not to provide the form.

What if I don’t have the payee’s TIN?

Missing TIN can trigger backup withholding under section 3406.

→ Ensure the TIN is entered if known; otherwise be aware backup withholding may apply.

Is the Additional Medicare Tax always 0.9%?

The 0.9% rate applies only to wages or compensation exceeding $200,000 in a calendar year.

→ Verify the payor’s wages exceed the $200,000 threshold before applying the tax.

Do I need a separate Form 4669 for each payee?

Each payee’s information must be documented individually for the relief request.

→ Count the number of payees and prepare one distinct Form 4669 per payee.

Can I use the same Form 4669 for multiple tax years?

The form includes a specific calendar year field and is required per year.

→ Check that the calendar year entered matches the year for which relief is sought.

Workflow map

Related forms and next steps

7 signals

Before

Form SS-4 – Application for Employer Identification Number, used to obtain the payor’s EIN referenced in Line 5.

Current

4669

After

Form 4670 – Request for Relief from Payment of Withholding Tax, transmits the completed Form 4669 to the IRS.

Often used with

Publication 15 – Employer’s Tax Guide, provides guidance on income tax withholding.Publication 1281 – Backup Withholding for Missing and Incorrect Name/TIN(s), explains backup withholding requirements.Publication 515 – Withholding of Tax on Nonresident Aliens and Foreign Entities, covers foreign person withholding.Form 8959 – Additional Medicare Tax, details the 0.9% Additional Medicare Tax.

⚠ If something goes wrong

  • Form 4670 – can be used to request relief when the payor failed to withhold the correct tax.

Questions about IRS Form 4669

What is IRS Form 4669 used for?

Form 4669 lets a payor show the IRS the payments it made and the taxes it withheld. The payor gets a completed copy from each payee and keeps it for its records. The form helps the payor qualify for relief if it under‑withheld tax.

Who must file IRS Form 4669?

Payors who are seeking relief from withholding tax must obtain a completed Form 4669 from each payee for the tax year.

What information does IRS Form 4669 require?

The form collects the payee’s name, address, and TIN; the calendar year; the payor’s name, address, and EIN; and the amounts of payments subject to income, backup, foreign, and Additional Medicare Tax withholding. The payee then confirms reporting details and signs under penalty of perjury.

Where do I file IRS Form 4669?

Do not send Form 4669 to the IRS; instead, give the completed form to the payor.

How do I complete IRS Form 4669?

The payor completes Part 1 lines 1‑6 with payee and payor information and the payment amounts. The payee reviews Part 1, corrects any errors, and fills Part 2 lines 7‑9 with reporting details. The payee then signs Part 3 under penalty of perjury. The completed form is returned to the payor for its records and for inclusion with Form 4670.

What happens if IRS Form 4669 is filed incorrectly?

If the payor withholds less than required, it remains liable for the full tax owed, and false statements expose the signer to penalties of perjury.

Do I send Form 4669 to the IRS?

The address on the form is for comments only, not for filing. Confirm you are delivering the form directly to the payor.

Am I required to fill out Form 4669 as the payee?

The form is primarily for the payor to request relief; the payee’s participation is optional. Check whether you are acting as the payor; if you are the payee, you may choose not to provide the form.

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Public DomainCreated by the U.S. federal government. Not subject to copyright (17 USC § 105). Freely copyable without restriction.
Public DomainCreated by the U.S. federal government. Not subject to copyright (17 USC § 105). Freely copyable without restriction.
Public DomainCreated by the U.S. federal government. Not subject to copyright (17 USC § 105). Freely copyable without restriction.
Public DomainCreated by the U.S. federal government. Not subject to copyright (17 USC § 105). Freely copyable without restriction.
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