Form 4669 - Statement Of Payments Received - Department Of Treasury
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1Department of the Treasury — Internal Revenue Service
4669
Form
Statement of Payments Received
(Rev. January 1993)
1. Name and Address of Payee
2. Social Security Number
3. Name and Address of Payor
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.
4669
Form
(Rev. 1-93)
Catalog Number 41877Z
Department of the Treasury — Internal Revenue Service
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