Form   8973          Certified Professional Employer Organization/Customer                                                                                                                               730118
(Rev. December 2018) 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 
       employees performing services for the customer. Check all that apply.          employees                     paid to employees

        Form 940, 940-PR (Employer’s Annual Federal Unemployment (FUTA) Tax Return)

        Form 941, 941-PR, 941-SS (Employer’s QUARTERLY Federal Tax Return)

        Form 943, 943-PR (Employer’s Annual Federal Tax Return for Agricultural 
        Employees)

        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. 12-2018)

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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 which 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. 12-2018)

                                                                                                          730318
Form 8973 (Rev. 12-2018)

                             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. 12-2018)