Form 4669 PDF Details

The Form 4669, Statement of Payments Received, is an essential document issued by the Department of the Treasury and managed by the Internal Revenue Service (IRS), designed to address specific tax-related situations. This form plays a crucial role for individuals who have received payments—be it commissions, bonuses, prizes, etc.—where federal income tax and social security tax were not withheld at the source. It requires detailed inputs such as the name and address of both the payee and payor, social security numbers, the total amount of non-withheld payments, and clarifies how these payments were reported in their tax return. Significantly, it involves a declaration under the penalties of perjury that the information provided is accurate and that the pertinent taxes due on these earnings have been paid in full. Beyond serving as a declaration, the form also includes a Privacy Act Notice, which educates the taxpayer about the legal grounds of the data collection, its purpose, and the consequences of non-compliance. This notice reaffirms the IRS's commitment to transparency and the protection of individual rights while emphasizing the importance of accurate and complete disclosure for tax compliance.

QuestionAnswer
Form NameForm 4669
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 4669 instructions, Payor, exclusions, exemptions

Form Preview Example

Form 4669

(Rev. January 1993)

Department of the Treasury — Internal Revenue Service

Statement of Payments Received

1. Name and Address of Payee

3. Name and Address of Payor

2. Social Security Number

4.Calendar Year

5.Amount of Payments (Including Commissions, Bonuses, Prizes, etc.) on Which Income Tax and Social Security Tax Were Not Withheld

$

The above Payments on which there was no withholding of federal income or social security tax, were reported on my tax return described below. The taxes due on that return have been paid in full.

6. Name and Address Shown on Return

7.Spouse’s Social Security Number if a Joint Return was Filed

8. Return Form Number

9. Service Center Where Filed

10. The Payments Shown in Item 5, Above, Are Reported On:

 

a. Line, ___________, Page ___________, of my return

b. Schedule ___________ of my return. If reported on Schedule C, F, or SE,

 

Self-Employment Tax of

 

$_________________________ was paid.

 

 

Under penalties of perjury, I declare that to the best of my knowledge and belief the above information is true, correct, and complete.

11. Signature of Payee

12. Date

For Privacy Act Notice, see back of form.

Form 4669 (Rev. 1-93)

Catalog Number 41877Z

Department of the Treasury — Internal Revenue Service

Privacy Act Notice

Under the Privacy Act of 1974 we must tell you:

■Our legal right to ask for the information and whether the law says you must give it.

■What major purposes we have in asking for it, and how it will be used.

■What could happen if we do not receive it.

The law covers:

■Tax returns and any papers filed with them.

■Any questions we need to ask you so we can:

Complete, correct, or process your return.

Figure your tax.

Collect tax, interest, or penalties.

Our legal right to ask for information is Internal Revenue Code sections 6001, 6011, and 6012(a), and their regulations. They say that you must file a return or statement with us for any tax you are liable for. Code section 6109 and its regulations say that you must show your social security number on what you file. This is so we know who you are, and can process your return and papers.

You must fill in all parts of the tax form that apply to you. But you do not have to check boxes for the Presidential Election Campaign Fund.

We ask for tax return information to carry out the Internal Revenue laws of the United States. We need it to figure and collect the right amount of tax.

We may give the information to the Department of Justice and to other Federal agencies, as provided by law. We may also give it to cities, states, the District of Columbia, and U.S. commonwealths or possessions to carry out their tax laws. And we may give it to foreign governments because of tax treaties they have with the United States.

If you do not file a return, do not provide the information we ask for, or provide fraudulent information, the law provides that you may be charged penalties and, in certain cases, you may be subject to criminal prosecution. We may also have to disallow the exemptions, exclusions, credits, deduc- tions, or adjustments shown on the tax return. This could make the tax higher or delay any refund. Interest may also be charged.

Please keep this notice with your records. It may help you if we ask you for other information.

If you have questions about the rules for filing and giving information, please call or visit any Internal Revenue Service office.

This is the only notice we must give you to explain the Privacy Act. However, we may give you other notices if we have to examine your return or collect any tax, interest, or penalties.

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1. You should fill out the form 4669 properly, hence take care when filling in the parts comprising all these fields:

disallow writing process detailed (portion 1)

2. Immediately after this section is done, proceed to type in the applicable details in these: Under penalties of perjury I, Signature of Payee, Date, SelfEmployment Tax of, was paid, Form Rev, Catalog Number Z, Department of the Treasury, and For Privacy Act Notice see back of.

For Privacy Act Notice see back of, was paid, and Under penalties of perjury I of disallow

Regarding For Privacy Act Notice see back of and was paid, make sure that you don't make any errors in this section. Both of these are the most significant fields in this file.

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