Certified Professional Employer Organization/Customer                                                                                                                            730123
Form 8973
(Rev. December 2023)                                             Reporting Agreement
Department of the Treasury  
Internal Revenue Service                                                                                                                                                                               OMB No. 1545-2266
Read the separate instructions before you complete Form 8973.

Part 1: Why are you filing this form? 

     A service contract started on        /                     /between the customer reported in Part 2 and the CPEO reported in Part 3.

     A service contract ended on                 /        /      between the customer reported in Part 2 and the CPEO reported in Part 3.

     Correcting a previously filed Form 8973.

Part 2: Customer Information

1    Customer’s employer identification number (EIN)                      —

2    Customer’s name (not your trade name)

3    Customer’s trade name (if any)

4    Address
                     Number                                Street                                                                                            Suite or room number

                     City                                                                                                                                                        State                 ZIP code

                     Foreign country name                                      Foreign province/county                                                                                            Foreign postal code

                                                                                                                                                             CPEO reports all wages/              CPEO reports some 
5    Identify forms that the CPEO will file reporting wages or compensation paid to                                                                          compensation paid to           wages/compensation paid 
     employees performing services for the customer. Check all that apply.                                                                                   employees                            to employees
     Form 940, Employer’s Annual Federal Unemployment (FUTA) Tax Return  
     (all 940 series)
     Form 941, Employer’s QUARTERLY Federal Tax Return 
     (all 941 series)
     Form 943, Employer’s Annual Federal Tax Return for Agricultural Employees  
     (all 943 series)

     Form CT-1, Employer’s Annual Railroad Retirement Tax Return 

Part 3: CPEO Information

  6     CPEO’s employer identification number (EIN)                      —

  7     CPEO’s name (not your trade name)

  8     CPEO’s trade name (if any)

  9     Address
                         Number                                 Street                                                                                                  Suite or room number

                         City                                                                                                                                                               State      ZIP code

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. www.irs.gov/Form8973                                                          Cat. No. 37796R                      Form 8973 (Rev. 12-2023)

                                                                                                                                  730223
Form 8973 (Rev. 12-2023)
Part 4: Customer Relationship Information

10      Is  the  CPEO’s  relationship  with  the  customer  reported  in  Part  2  subject  to  a  contract 
        described under section 7705(e)(2) (also called a CPEO contract)?              . . . . .  . . .     Yes      No*
                                                                                                            *If “No,” skip lines 11–13. 
11      Is the customer reported in Part 2 a provider of employment-related services (for example, 
        a professional employer organization)? . . . . . . .                  . .      . . . . .  . . .     Yes      No

12      Is the customer reported in Part 2 a related party of the CPEO?   .            . . . . .  . . .     Yes      No

13      Does  the  CPEO  apply  the  exemptions,  exclusions,  definitions,  and  other  rules  that  are 
        based  on  type  of  employer  under  sections  3511(a)(2)  and  3511(c)(2)  to  the  customer 
        reported in Part 2?      . . . . . . . . . . . . . .                  . .      . . . . .  . . .     Yes      No

Part 5: Customer Signature

I declare that I have examined this form, and to the best of my knowledge and belief, Parts 1, 2, and 4 are true, correct, and complete. I certify that 
I have the authority to execute this form for the customer reported in Part 2.

Sign your                                                                       Print your 
name here                                                                       name here
                                                                                Print your 
                                                                                title here
        Date            /       /

Email address                                                                   Best daytime phone

Part 6: CPEO Signature

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. I 
certify that I have the authority to execute this form for the CPEO reported in Part 3.

Sign your                                                                       Print your 
name here                                                                       name here
                                                                                Print your 
                                                                                title here
        Date            /       /

Email address                                                                   Best daytime phone

Page 2                                                                                                          Form 8973 (Rev. 12-2023)

                                                                                                  730323
Form 8973 (Rev. 12-2023)

                                 CPEO Consent to Disclosure of Tax Information
To maintain certification, a Certified Professional Employer Organization (CPEO) must complete this consent 
to disclose tax information to the customer reported on Form 8973 and send it to the IRS.
By signing, dating, and entering my employer identification number (EIN) at the bottom of this page, I 
hereby consent, to the extent necessary to carry out the purposes of the CPEO program, to the IRS 
disclosing, to the customer named below, information from my employment tax returns (for example, Forms 
940 and 941) filed with respect to the customer named below. This consent also covers the disclosure of any 
information regarding my obligations to report, deposit, and pay federal employment taxes for the customer 
named below. I also consent to the disclosure of information about my certification, regardless of year.
The customer named below is authorized to inspect and/or receive the confidential tax information 
identified above for the tax forms and tax periods listed below. See the instructions for details on how to 
report the tax periods.

                                                  —
Customer’s name (from Form 8973, Part 2)          Customer’s EIN (from Form 8973, Part 2)

       Tax Form Number                            Year(s) or Period(s)
       (940, 941, 943, CT-1)

I understand that the information to be disclosed is generally confidential under the laws applicable to the IRS and that the customer receiving the 
information is not bound by these laws and may use the information for any purpose as permitted by other federal laws and/or state laws. I certify 
that I have the authority to execute this consent.

Sign your                                         Print your 
name here                                         name here
                                                  Print your 
                                                  title here
       Date             /       /

CPEO’s EIN                       —

CPEO’s name
Page 3                                                                                   Form 8973 (Rev. 12-2023)