Department of the Treasury - Internal Revenue Service
Form 4669                                                                                                    OMB Number 
                                                                                                             1545-0364
(December 2014)              Statement of Payments Received
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                                                 $
b. Payments subject to Backup Withholding                                                     $
c. Payments to Foreign Persons subject to Withholding Tax                                     $
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 on the payee's tax return

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
b. Schedule                  on my Form                   return for tax year
9.  The payments shown above on line 6d are either
a. Reported on my return on Line                   on Form 8959 attached to my Form 1040 return for tax year          .
   The taxes due on the return have been paid in full.
OR
b. I was not liable for Additional Medicare Tax for tax year                  because I filed a joint tax return with my spouse 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. 

Part 3 - Sign here (To be completed by payee)
Under penalties of perjury, I declare that I have examined this form and, to the best of my knowledge and belief it is true, correct, and 
complete.
Payee name (print)                      Payee title (print)                  Best daytime telephone number

Payee signature                                                              Date (MM-DD-YYYY)

Catalog Number 41877Z                                     www.irs.gov                        Form 4669 (Rev. 12-2014)

                                                                                                                                             Page 2

             Instructions for Form 4669, Statement of Payments Received
Form 4669, Statement of Payments Received                                  Line 6a: Enter the amount of payments subject to income tax 
                                                                                  withholding.   
Section and chapter references are to the Internal Revenue Code 
unless otherwise noted.                                                    Line 6b: Enter the amount of payments subject to backup withholding. 
Form 4669 is subject to review by the IRS.                                 Line 6c: Enter the amount of payments made to a foreign person 
                                                                                  (individual or entity) subject to withholding tax.   
General Information 
                                                                           Line 6d: Enter the amount of payments subject to Additional Medicare 
If a payor withholds less than the correct amount of tax, it is liable for        Tax withholding.   
the correct amount that it was required to withhold. 
                                                                           Instructions for the Payee 
Section 3402 requires employers to withhold income tax on payments 
of wages, including reclassified wages and fringe benefits subject to      Part 1 
federal income tax withholding. Employers are also responsible under 
sections 3102 and 3202 for withholding a 0.9% Additional Medicare          Review the entries in Part 1 provided by the payor.  If any of the 
Tax from wages or compensation paid to an employee in excess of            information is incorrect, cross out the incorrect information and enter 
$200,000 in a calendar year.  For more information on income tax           the correct information.  Ask the payor to correct its records.   
withholding or Additional Medicare Tax, see Publication 15 (Circular       Part 2 
E), Employer’s Tax Guide, the Instructions for Form 8959, or visit 
www.irs.gov.                                                               Any reference to Form 1040 includes any return in the Form 1040 
                                                                           series (e.g., Form 1040, Form 1040NR, Form 1040-SS, Form 1040-
Under section 3406, in the case of a reportable payment a payor is         PR, Form 1040A, 1040EZ, or 1040NR-EZ). 
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   Line 7: Enter the payee’s name(s) and address exactly as it appears 
the payee’s taxpayer identification number in the manner required).               on the payee’s tax return. 
This withholding is referred to as “backup withholding.”  For more 
information on “backup withholding” see Publication 1281, Backup           For payments subject to income tax withholding, payments subject to 
Withholding for Missing and Incorrect Name/TIN(s), or visit www.irs.       backup withholding, or payments to a foreign person (individual or 
gov and enter the term “backup withholding” in the search box.             entity) subject to withholding tax, complete either line 8a or 8b as 
                                                                           appropriate. 
Payors may also be required to withhold tax on certain payments 
made to a foreign person (individual or entity) subject to withholding     Lines 8a and 8b: Specify the form on which the payments were 
tax under chapters 3 and 4.  For more information see Publication                       reported and the line or schedule of the return. Enter 
515, Withholding of Tax on Nonresident Aliens and Foreign Entities.                     the tax year of the return. 
Purpose of form                                                            For payments subject to Additional Medicare Tax, complete either 9a 
                                                                           or 9b, as appropriate. 
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            Line 9a: Check the box in line 9a if the payee reported the payments 
Regulations section 1.1474-4, if the payor can show that the payee                on Form 8959, attached to Form 1040.  Specify the line on 
reported the payments and paid the corresponding tax. Form 4669 is                Form 8959 on which the payments were reported. Enter the 
used by a payor to show that it is entitled to such relief.                       tax year of the return. 
A separate, completed Form 4669 must be obtained by the payor              Line 9b: Check the box in line 9b if the payee filed using married filing 
from each payee for each year relief is requested. After the payor                jointly status on Form 1040 and did not have total Medicare 
obtains Forms 4669 for a specific year, the Form 4670, Request for                wages and tips and self-employment income of more than 
Relief from Payment of Withholding Tax, is used to transmit the                   $250,000 or total railroad retirement (RRTA) compensation 
Forms 4669 for each tax year. A payor should retain a copy of this                of more than $250,000.  The payee was not liable for 
information for its files.                                                        Additional Medicare Tax.   
Specific Instructions                                                      Part 3. Payee Signature 
Instructions for the Payor                                                 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 
Part 1                                                                     applicable). Providing a daytime phone number may help speed 
                                                                           processing. Return the signed form to 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 
       payments. 
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.

Catalog Number 41877Z                                           www.irs.gov                                  Form 4669 (Rev. 12-2014)

                                                                                                                                       Page 3
                             Privacy Act and Paperwork Reduction Act Notice
We ask for the information on this form to carry out the Internal Revenue laws of the United States. Subtitle C, Employment Taxes, of the 
Internal Revenue Code requires tax withholding on wages and railroad retirement (RRTA) compensation. Additionally, section 3406 requires 
backup withholding on certain payments, and chapters 3 and 4 require tax withholding on certain payments to foreign persons. This form is 
used to determine whether the payor is eligible for relief from payment of tax withholding based on payments made to you. You are not required 
to provide this information to the payor. Not providing this information, or providing incomplete information, may delay or prevent the payor’s 
request for relief. If you choose to provide this information, providing false or fraudulent information may subject you to penalties. 
Generally, tax returns and return information are confidential, as required by section 6103. However, section 6103 allows or requires the IRS to 
disclose or give the information to others as described in the Code. We may disclose your tax information to the Department of Justice for civil 
and criminal litigation, and to cities, states, the District of Columbia, and U.S. commonwealths and possessions to administer their tax laws. We 
may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or 
to federal law enforcement and intelligence agencies to combat terrorism. 
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a 
valid OMB control number. Books or records relating to a form or instructions must be retained as long as their contents may become material 
in the administration of any Internal Revenue law. The time needed to complete and file this form will vary depending on individual 
circumstances. The estimated burden for individual taxpayers filing this form is approved under OMB control number 1545-0364 and is included 
in the estimates shown in the instructions for their individual income tax return. The estimated burden for all other taxpayers who file this form is 
shown below. 
Recordkeeping: 5 min.  
Learning about the law or the form: 4 min.  
Preparing the form:  4 min.  
Copying, assembling, and sending the form:  2 min. 
If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear 
from you. You can send your comments to  www.irs.gov/formspubs Click on “More Information” and then click on “Give us feedback on forms 
and publications”. Or you can send your comments to Internal Revenue Service, Tax Forms and Publications Division, 1111 Constitution Ave. 
NW, IR-6526, Washington, DC 20224. Do not send Form 4669 to this address. Instead, give Form 4669 to the payor.

Catalog Number 41877Z                              www.irs.gov             Form 4669 (Rev. 12-2014)