Department of the Treasury - Internal Revenue Service 
Form 4670
(Rev. 1-2004)             Request for Relief from Payment of Income Tax Withholding

Name and address of payor                          Payor identification number           Return form number

                                                   Tax period covered by Examination
                                                   From:
                                                   To:
As provided by Internal Revenue Code section 3402(d), explained on the back of this form, please relieve me from the payment of income tax 
required to be withheld from payments covered by the attached Forms 4669, Statement of Payments Received, listed below.

                          Year                     Number of Statements

                          Total statements attached

I certify that either (1) the statements were signed in my presence, or (2) to the best of my knowledge and belief the signatures on the state- 
ments are valid and legal.
                                                                                         Date

                                                                                         Date

          Signatures
                                                   Title                                 Date
                    By
Catalog  No. 23290O           www.irs.gov                                           Form 4670 (Rev. 1-2004)

                                             Instructions for Payor

Section 3402(d) of the Internal Revenue Code provides that you can be relieved of payment of
income tax not withheld from a payee, provided you can show that the payee has reported the 
payments and paid the tax. You should obtain a separate Form 4669, Statement of Payments 
Received, from each payee for each year relief is requested. However, you are still liable for any 
penalty or addition to the tax that applies to your failure to deduct and withhold. After you get all 
Statements of Payments Received, please summarize them by year on the front of this form, 
and send them with this form to the Internal Revenue Service Center at the address for your location.

Exception for exempt organizations and government entities- If you are filing Form 4670 for
an exempt organization or government entity (Federal, state, local, or Indian tribal government), 
use the following address regardless of your location:  Ogden, UT  84201-0046

Connecticut, Delaware, District of Columbia,                      Cincinnati, OH  45999-0005
Illinois, Indiana, Kentucky, Maine, Maryland,
Massachusetts, Michigan, New Hampshire,
New Jersey, New York, North Carolina,
Ohio, Pennsylvania, Rhode Island,
South Carolina, Vermont, Virginia,
West Virginia, Wisconsin

Alabama, Alaska, Arizona, Arkansas, California,                       Odgen, UT  84201-0005
Colorado, Florida, Georgia, Hawaii, Idaho, Iowa,
Kansas, Louisiana, Minnesota, Mississippi,
Missouri, Montana, Nebraska, Nevada, New Mexico,
North Dakota, Oklahoma, Oregon, South Dakota,
Tennessee, Texas, Utah, Washington, Wyoming

If you have no legal residence or principal place of business in any state, file with the Internal
Revenue Service Center, Philadelphia, PA  19255-0005.

Important:  It is to your advantage to file this form and the required attachments at the earliest
possible date, to avoid collection action.

Catalog  No. 23290O                             www.irs.gov                                           Form 4670 (Rev. 1-2004)