Department of the Treasury - Internal Revenue Service
 Form 4670                                                                                                                                                                        OMB Number 
                                       Request for Relief of Payment of  
 (August 2015)                                                                                                                                                                          1545-0343
                                           Certain Withholding Taxes

 Employer identification number            —                                                                                                                      Tax return (check one)
 (EIN)                                                                                                                                                            Form 941              Form 945
 Name (not your trade name)                                                                                                                                       Form 943              Form CT-1
                                                                                                                                                                  Form 944              Form 1042
 Trade name (if any)
                                                                                                                                                                  Tax year (enter one year)
 Address
        Number                           Street                                                                                               Suite or room number
                                                                                                                                                                             yyyy
        City                                                         State        ZIP code
                                                                                                                                                                  Number of Form 4669s attached 

        Foreign country name                 Foreign province/county       Foreign postal code

I request to be relieved from liability for payment of taxes required to be withheld from the payments identified on the 
attached Forms 4669, Statement of Payments Received. 
 
Under penalties of perjury, I declare that I have examined this form and the accompanying attachments, and to the best of my 
knowledge and belief, they are true, correct, and complete.

                                                                                  Print your  
 Sign your                                                                        name here 
✗ name here                                                                       Print your  
                                                                                  title here 

            Date            /        /                                            Best daytime phone 

Purpose of Form 
Section and chapter references are to the Internal Revenue Code unless otherwise noted. 
If a payor (including a withholding agent) withholds less than the correct amount of tax it is liable for the correct amount that it was required to withhold. 
Form 4670 is used to submit Forms 4669, Statement of Payments Received, to the IRS. The Internal Revenue Code and regulations provide that a 
payor can be relieved of the payment of some taxes provided the payor can show that the payee has reported the payments and paid the tax. Form 
4669 is used to show that the payee has reported the payments and paid the tax.   
Note:  The payor is still liable for any penalty or addition to the tax that applies to the failure to deduct and withhold. 
General Instructions 
You should obtain a separate Form 4669 from each payee for each year relief is requested. After you obtain the Forms 4669, complete and sign a Form 
4670 for each tax form and each tax year for which you are requesting relief.  Attach Forms 4669, any examination reports, and any amended return to 
Form 4670. Retain copies for your records. 
 •   For payments subject to Income Tax Withholding, Backup Withholding, or Additional Medicare Tax, attach a copy of the examination report. If the 
 tax for which relief is requested has been paid, you must also complete the appropriate adjusted return or claim form (Form 941-X, Form 943-X, 
 Form 944-X, Form 945-X or Form CT-1X).   
 •   For payments to foreign persons subject to withholding tax, attach a copy of the Form 4549/4549-A (Income Tax Examination Changes). 
Important: It is to your advantage to submit this form and the required attachments at the earliest possible date, to avoid collection action. 
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 www.irs.gov.

Catalog Number 23290O                                www.irs.gov                                                                                                             Form 4670 (Rev. 8-2015)

                                                                                                                                                        Page 2
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. 
Withholding agents 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.  For more information see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities.  Regulations section 
1.1441-1(b)(7) provides that a withholding agent may provide a Form 4669 to establish the amount of tax, if any, actually paid by or for the beneficial 
owner of the income 
Where to File 
If Form 4670 is related to an examination that is still ongoing or has ended in the past 30 days, submit Form 4670 with required attachments to the IRS 
Examiner with whom you are working. 
If Form 4670 is related to an examination that concluded more than 30 days ago, or is not related to an examination, submit Form 4670 with required 
attachments to the address provided below:
IF you are in...                                                                                      THEN use this address...
Special filing address for exempt organizations; federal, state, and local governmental entities; and Department of the Treasury 
Indian tribal governmental entities; regardless of location                                           Internal Revenue Service 
                                                                                                      Ogden, UT 84201-0005
No legal residence or principal place of business in any state or if Form 4670 is related to Form     Internal Revenue Service 
1042                                                                                                  P.O. Box 409101 
                                                                                                      Ogden, UT 84409
Connecticut, Delaware, District of Columbia, Florida, Georgia, Illinois, Indiana, Kentucky, Maine,    Department of the Treasury 
Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina,               Internal Revenue Service 
Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Vermont, Virginia, West Virginia,        Cincinnati, OH 45999-0005
Wisconsin
Alabama, Alaska, Arizona, Arkansas, California, Colorado, Hawaii, Idaho, Iowa, Kansas, Louisiana,  Department of the Treasury 
Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Mexico, North Dakota,                Internal Revenue Service 
Oklahoma, Oregon, South Dakota, Texas, Utah, Washington, Wyoming                                      Ogden, UT 84201-0005

Specific Instructions 
Employer Identification Number, Name, and Address 
Type or print your employer identification number (EIN), name, and address in the spaces provided. Do not use your social security number (SSN) or 
individual taxpayer identification number (ITIN). Generally, enter the business (legal) name you used when you applied for your EIN on Form SS-4, 
Application for Employer Identification Number. 
Tax Return and Tax Year Covered 
Check the form type and enter the tax year for which relief from payment of taxes is requested.  For example, if tax was reported on your Forms 941 for 
tax year 2013, check the box for Form 941 and enter 2013 in the space provided. 
Do not enter more than one form type or tax year on Form 4670.  If more than one tax year or more than one tax form was examined, submit a separate 
Form 4670 for each form type and tax year for which you are requesting relief. Each Form 4670 must have attached the required documentation 
corresponding to the form type and tax year you specify on Form 4670.  See General Instructions above for the required documentation. 
Number of Statements Attached 
In the space provided, enter the number of Forms 4669 you are attaching to your Form 4670. 
Signature 
You must complete all sections of Form 4670 and sign it.  If you do not sign, your Form 4670 will be returned to you for your signature. 
Form 4670 must be signed by one of the following: 
•   Sole proprietorship—The individual who owns the business. 
•   Corporation (including a limited liability company (LLC) treated as a corporation)—The president, vice president, or other principal officer duly 
authorized to sign. 
•   Partnership (including an LLC treated as a partnership) or unincorporated organization—A responsible and duly authorized member, partner, or 
officer having knowledge of its affairs. 
•   Single member LLC treated as a disregarded entity for federal income tax purposes—The owner of the LLC or a principal officer duly authorized to 
sign. 
•   Trust or estate—The fiduciary. 
Form 4670 may also be signed by a duly authorized agent of the taxpayer if a valid power of attorney has been filed.

                                          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 you 
are eligible for relief from payment of tax withholding and the amount, if any, of relief. You are not required to apply for relief from payment of tax 
withholding; however, if you do apply you are required to give us the information requested on this form. We need it to determine your eligibility for relief 
and to figure and collect the right amount of tax. Section 6109 requires you to provide your identification number. Failure to provide the information we 
ask for may delay or prevent processing of your request; providing false or fraudulent information may subject you to penalties.
Catalog Number 23290O                                         www.irs.gov                                             Form 4670 (Rev. 8-2015)