Enlarge image
Hiring Incentives to Restore Employment (HIRE) Act
Form W-11 OMB No. 1545-2173
(Rev. June 2010) Employee Affidavit
Department of the Treasury
Internal Revenue Service ▶ Do not send this form to the IRS. Keep this form for your records.
To be completed by new employee. Affidavit is not valid unless employee signs it.
I certify that I have been unemployed or have not worked for anyone for more than 40 hours during the 60-day period ending on the
date I began employment with this employer.
Your name Social security number ▶
First date of employment / / Name of employer
Under penalties of perjury, I declare that I have examined this affidavit and, to the best of my knowledge and belief, it is true, correct,
and complete.
Employee's signature▶ Date ▶/ /
Instructions to the • is not related to you. An employee is Our legal right to ask for information is
related to you if he or she is your child or Internal Revenue Code section 6001 and
Employer a descendent of your child, your sibling the purpose of the form is stated in the
Section references are to the Internal or stepsibling, your parent or an instructions. This collection of the
Revenue Code. ancestor of your parent, your stepparent, information is required to obtain certain
your niece or nephew, your aunt or tax benefits.
Purpose of Form uncle, or your in-law. An employee also If you do not retain this record or give
is related to you if he or she is related to fraudulent information, we may have to
Use Form W-11 to confirm that an anyone who owns more than 50% of disallow certain exemptions and credits,
employee is a qualified employee under your outstanding stock or capital and and you also may be charged penalties
the HIRE Act. You can use another profits interest or is your dependent or a and be subject to criminal prosecution.
similar statement if it contains the dependent of anyone who owns more This could make the tax higher or delay
information above and the employee than 50% of your outstanding stock or any refund. Interest may also be
signs it under penalties of perjury. capital and profits interest. charged.
Only employees who meet all the If you are an estate or trust, see The time needed to complete this form
requirements of a qualified employee section 51(i)(1) and section 152(d)(2) for will vary depending on individual
may complete this affidavit or similar more details. circumstances. The estimated average
statement. You cannot claim the HIRE
Act benefits, including the payroll tax Do not send this form to the IRS. time is:
exemption or the new hire retention ¶CAUTION! Keep it with your other payroll Recordkeeping . . . . 1 hr., 25 min.
credit, unless the employee completes and income tax records. Preparing the form . . . . 25 min.
and signs this affidavit or similar
statement under penalties of perjury and Learning about the
is otherwise a qualified employee. Paperwork Reduction Act Notice.The law or the form . . . . . 24 min.
Paperwork Reduction Act of 1980
A “qualified employee” is an employee requires that when we ask you for If you have comments regarding the
who: information we must first tell you our accuracy of this time estimate or you
• begins employment with you after legal right to ask for the information, why have suggestions for making this form
February 3, 2010, and before January 1, we are asking for it, and how it will be simpler, we would be happy to hear from
2011; used. We must also tell you what could you. You can write to the Internal
happen if we do not receive it and Revenue Service, Tax Products
• certifies by signed affidavit, or similar whether your response is voluntary, Coordinating Committee,
statement under penalties of perjury, that required to obtain a benefit, or SE:W:CAR:MP:T:T:SP, 1111 Constitution
he or she has not been employed for mandatory under the law. You are not Ave. NW, IR-6526, Washington, DC
more than 40 hours during the 60-day required to provide the information 20224. Do not send the form to this
period ending on the date the employee requested on a form that is subject to address.
begins employment with you; the Paperwork Reduction Act unless the Please keep this notice with your
• is not employed by you to replace form displays a valid OMB control records. It may help you if we ask you for
another employee unless the other number. Books or records relating to a other information. If you have any
employee separated from employment form or its instructions must be retained questions about the rules for filing and
voluntarily or for cause (including as long as their contents may become giving information, please call or visit any
downsizing); and material in the administration of any Internal Revenue Service office.
Internal Revenue law. Generally, tax
returns and return information are
confidential, as stated in Code section
6103.
Cat. No. 10744F Form W-11 (Rev. 6-2010)