IRS · Official form

Form 4669, Statement of Payments Received

Form 4669 is the payee’s signed statement that they reported and paid tax on payments a payer failed to withhold on. Fill in the official PDF below and download it.

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What is 4669?

Form 4669, Statement of Payments Received, is completed by the person who received payments when the payer did not withhold the required tax. The payee certifies the payments were included on their own return and the tax was paid, and the payer collects these statements to support relief from paying that tax again.

The payer typically submits the collected Forms 4669 with Form 4670, Request for Relief of Payment of Certain Withholding Taxes. Relief covers the tax itself; it does not remove interest or penalties the payer may owe for the failure to withhold.

Who files 4669?

Payees asked by an employer or other payer to certify that they reported payments and paid the related tax
Employers and payers who failed to withhold income or other required tax and are assembling support for relief
Businesses under an employment tax examination that misclassified workers or missed backup withholding

How to fill out 4669

Fill in the payee’s name, address, and taxpayer identification number at the top of the form.
Identify the payer and describe the payments: the type of payment, the year, and the amount received.
Certify that the payments were reported on the payee’s return and the tax was paid, as the form’s statement describes.
Sign and date the form; unsigned statements do not support relief.
Download the PDF and return it to the payer, who attaches it to Form 4670 when requesting relief from the IRS.

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Page 1 26 fields

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

6. Amount of payments. b. Payments subject to Backup Withholding

6. Amount of payments. c. Payments to Foreign Persons subject to Withholding Tax

6. Amount of payments. 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

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

on my Form

return for tax year

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

on my Form

return for tax year

9. The payments shown above on line 6d are either. a. Reported on my return on Line [entered line number] on Form 8959 attached to my Form

Reported on my return on Line [enter line number] on Form 8959 attached to my Form 1040 return for tax year [entered tax year]. The taxes

Reported on my return on Line [entered line number] on Form 8959 attached to my Form 1040 return for tax year [enter tax year]. The taxes

9. The payments shown above on line 6d are either. b. I was not liable for Additional Medicare Tax for tax year [entered tax year] because

I was not liable for Additional Medicare Tax for tax year [enter tax year] because I filed a joint tax return with my spouse and did not

Part 3 - Sign here (To be completed by payee). Payee name (print)

Payee title (print)

Best daytime telephone number

Payee signature

Date (2 digit month - 2 digit day - 4 digit year format)

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Frequently asked questions

Who signs Form 4669, the payer or the payee?

The payee, the person who received the payments, signs it. The payer gathers the signed forms from each payee and submits them with Form 4670.

Does Form 4669 wipe out penalties for the payer?

No. It supports relief from paying the tax that should have been withheld, because the payee already paid it. Interest and applicable penalties for the failure to withhold can still apply.

What if a payee refuses to complete the form?

The payer cannot compel a payee to sign. Without a completed Form 4669 for a payee, the payer generally remains liable for that payee’s share of the tax.

Form 4669, Statement of Payments Received

What is 4669?

Who files 4669?

How to fill out 4669

Quick fill 4669 on this page

Frequently asked questions

Related forms

Form 941, Employer’s Quarterly Federal Tax Return

Form 941-X, Adjusted Employer’s Quarterly Federal Tax Return or Claim for Refund

Form 945, Annual Return of Withheld Federal Income Tax