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                                Statement of Liability of Lender, Surety, or 
Form 4219                                                                                                                 OMB Number 
(Rev. May 2014)                 Other Person for Withholding Taxes                                                        1545-2254
                                                  Under Section 3505 of the Internal Revenue Code 
                                                       (Please file this form in duplicate)
                Information relating to Employer (Borrower) for whom wages paid or to whom funds supplied
1. Name of employer (as used on employment tax return)                                            2. Employer identification number

3. Trade name, if other than above                                                                4. Date quarter ended (See item 4 of 
                                                                                                    instructions)

5. Address (Number, street, city, State, ZIP code)

     Information about the person making the wage payments for, or supplying funds to, the above Employer (Borrower)
6. Name

7. Address (Number, street, city, State, ZIP code)

8. Identification of project(s), contract(s), etc., for which wages paid or funds supplied

                                                                          a. Income tax
Computation of        9. Amount of employees taxes required to be 
                                                                          b. FICA tax
Liability for               withheld by employer
Withholding Taxes                                                         c. Railroad retirement tax
on Wages Paid 
Directly to         10. Total taxes required to be withheld by employer (Sum of Items 9a, b, and c)
Employees of        11. Portion of Item 10 paid by employer
Borrower
                    12. Liability for withholding taxes (Item 10 minus Item 11. Enter here and in Item 19.)
                    13. Amount supplied to employer for paying wages      $
                                                                          a. Income tax
Computation of      14. Amount of employee taxes required to be 
                                                                          b. FICA tax
Liability for               withheld by employer
Withholding Taxes                                                         c. Railroad retirement tax
on Funds Supplied   15. Total taxes required to be withheld by employer (Sum of Items 14a, b, and c)
for Specific 
Purpose of Paying   16. Portion of Item 15 paid by employer
Wages               17. Balance of Item 15 not paid by employer (Item 15 minus Item 16)
                    18. Liability for withholding taxes (The lesser of Item 17 or 25 percent of Item 13. Enter here 
                            and in Item 20.)
                    19. Liability where wages paid directly to employees (Item 12)
                    20. Liability where funds supplied for payment of wages (Item 18)
Total               21. Total liability for withholding taxes (Sum of Items 19 and 20)
Liability
                    22. Interest liability
                    23. Total liability (Sum of Items 21 and 22)
Under the penalties of perjury, I declare that I have examined this statement, and to the best of my knowledge and belief, it is true, correct, 
and complete. Declaration of preparer (other than taxpayer) is based on all information of which he/she has any knowledge.
Signature of lender, surety, or other person                    Title                                                 Date

Signature of preparer, if other than above                      Title                                                 Date

Form 4219 (Rev. 5-2014)     Catalog Number 41456S             www.irs.gov                  Department of the Treasury—Internal Revenue Service



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Form 4219 (Rev. 5-2014)                                                                                                                                           Page 2
                                                         General Instructions
Who must file Form 4219—File this form if you are a lender, surety, or                  For purposes of section 3505(b), an organization is deemed to have 
other person who, by reason of having paid wages directly to employees                  actual notice or knowledge of any fact relating to a transaction from the 
of another employer, or having supplied funds for the purpose of paying                 time that fact is brought to the attention of the individual conducting the 
wages to employees of another employer, has incurred liability under                    transaction, and in any event from the time that fact would have been 
section 3505 of the Internal Revenue Code for taxes required to be                      brought to the individual's attention if the organization had exercised due 
withheld. If you are an employer within the meaning of code section 3401                diligence, as defined in Code section 6323(i)(1).
(d)(1) or (d)(2) and the related regulations, do not use Form 4219 to                   The liability under section 3505 does not extend to the portion of the 
report income tax withholding.                                                          employer's taxes imposed under the Federal Insurance Contributions Act 
Internal Revenue Code—Section 3505(a) provides that if a lender,                        or the Railroad Retirement Tax Act. Under Section 3505, the employer 
surety, or other person pays wages directly to employees of another                     remains liable for withholding taxes not paid by the lender, surety, or 
employer, or to an agent of such employees, the lender, surety, or other                other person, and is required to file an employment tax return for such 
person is liable for payment to the United States of a sum equal to the                 wages paid by the employer, a lender, surety, or other person, and 
following taxes (and interest) required to be withheld from such wages by               furnish statements to employees of taxes withheld.
the other employer:                                                                     Separate Form 4219 for each employer and each calendar quarter—
(a) FICA tax required to be withheld under section 3102;                                A separate Form 4219 should be submitted, in duplicate, for each 
(b) Railroad retirement tax required to be withheld under section                       employer and for each calendar quarter for which liability under section 
     3202; and                                                                          3505 is incurred. 
(c) Income tax required to be withheld under section 3402.                              Where to file—File Form 4219 with the office of the Internal Revenue 
                                                                                        Service where the employer for whom wages were paid or funds were 
Section 3505(b) provides that if a lender, surety, or other person supplies             supplied files Federal employment tax returns.
funds to or for the account of another employer for the specific purpose 
of paying wages of the employees of the other employer, with actual                     Payment—Include with each Form 4219 a remittance (check or money 
notice or knowledge that the employer does not intend, or will not be                   order) for the amount shown in item 23, payable to the United States 
able, to make timely payment or deposit of the above taxes required to                  Treasury. Payment of the withholding taxes shown on Form 4219 by 
be withheld by the employer, the lender, surety, or other person is liable              either the employer or the lender, surety, or other person satisfies the 
for payment to the United States of a sum equal to the taxes, plus any                  liability. If neither the employer nor the lender, surety, or other person 
interest, that are not paid by the employer. However, the liability under               pays these taxes, the U.S. Government may collect the unpaid amount 
section 3505(b) cannot exceed 25% of the amount supplied specifically                   by appropriate civil action. To avoid the accumulation of interest, make 
for the purpose of paying of wages.  Section 3505(b) does not apply to                  the payment on or before the due date of the employer's (borrower's) 
ordinary working capital loans to employers, even though it is known that               Federal employment tax return.
part of the funds advanced will be used to pay wages.

                                                         Specific Instructions
Item 4. Enter the last day of the calendar quarter during which the wages               Item 14. Enter in items 14a, b, and c the amounts of employee taxes 
were actually paid to the employees of another employer. If funds were                  required to be withheld by the employer from wages paid during this 
supplied to the employer for payment of wages, show the last day of the                 quarter with funds supplied for that specific purpose.
calendar quarter during which the wages were actually paid by the                       Item 22. If the liability is paid after the due dates of the employer's 
employer.                                                                               Federal employment tax return, interest will be charged at the annual 
Item 9. Enter in items 9a, b, and c the amounts of employee taxes                       rate established under Internal Revenue Code section 6621(a) subject to 
required to be withheld as if the wages were paid by the employer.                      adjustments as provided in section 6621(b).
Item 13. Enter the gross amount (without reduction for withholding taxes) 
supplied to the employer for the specific purpose of paying wages which 
were actually paid during this quarter. 

                                        Privacy Act and Paperwork Reduction Act Notice
We ask for the information on Form 4219 to carry out the Internal Revenue laws          example, we may disclose your tax information to the Department of Justice for civil 
of the United States. We need it to figure and collect the right amount of tax.         and criminal litigation, and to cities, states, the District of Columbia, and U.S. 
Subtitle C, Employment Taxes, of the Internal Revenue Code imposes employment           commonwealths and possessions for use in administering their tax laws. We may 
taxes on wages, including income tax withholding. Form 4219 is used to determine        also disclose this information to other countries under a tax treaty, to federal and 
if you as a lender, surety or other person who paid wages directly to employees of      state agencies to enforce federal nontax criminal laws, or to federal law 
another employer, has incurred liability under section 3505 for taxes required to be    enforcement and intelligence agencies to combat terrorism.
withheld. Section 6011 requires you to provide the requested information if the tax     The time needed to complete and file Form 4219 will vary depending on 
is applicable to you. Section 6109 requires you to provide your identification          individual circumstances. The estimated average time is: Recordkeeping, 11 hr.; 
number. If you fail to provide this information in a timely manner, or provide false or Learning about the law or the form, 50 min.; Preparing, copying, assembling, 
fraudulent information, you may be subject to penalties.                                and sending the form to the IRS, 1 hr.
You are not required to provide the information requested on a form that is             If you have comments concerning the accuracy of these time estimates or 
subject to the Paperwork Reduction Act unless the form displays a valid OMB             suggestions for making Form 4219 simpler, we would be happy to hear from you. 
control number. Books and records relating to a form or its instructions must be        You can email us at taxforms@irs.gov. Enter “Form 4219” on the subject line. Or 
retained as long as their contents may become material in the administration of any     write to: Internal Revnue Service, Tax Products Coordinating Committee, SE:W:
Internal Revenue law.                                                                   CAR:MP:T:M:S, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224. Do 
Generally, tax returns and return information are confidential, as required by          not send Form 4219 to this address. Instead, see Where to File? in the instructions 
section 6103. However, section 6103 allows or requires the IRS to disclose or give      for Form 4219.
the information shown on your tax return to others as described in the Code. For

Form 4219 (Rev. 5-2014)        Catalog Number 41456S                             www.irs.gov          Department of the Treasury—Internal Revenue Service






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