Form 4670 - Request For Relief Of Payment Of Certain Withholding Taxes - 2015

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Department of the Treasury - Internal Revenue Service
Request for Relief of Payment of
OMB Number
(August 2015)
Certain Withholding Taxes
Tax return
(check one)
Employer identification number
Form 941
Form 945
Form 943
Form CT-1
Name (not your trade name)
Form 944
Form 1042
Trade name (if any)
Tax year
(enter one year)
Suite or room number
ZIP code
Number of Form 4669s attached
Foreign country name
Foreign province/county
Foreign postal code
I request to be relieved from liability for payment of taxes required to be withheld from the payments identified on the
attached Forms 4669, Statement of Payments Received.
Under penalties of perjury, I declare that I have examined this form and the accompanying attachments, and to the best of my
knowledge and belief, they are true, correct, and complete.
Print your
name here
Sign your
name here
Print your
title here
Best daytime phone
Purpose of Form
Section and chapter references are to the Internal Revenue Code unless otherwise noted.
If a payor (including a withholding agent) withholds less than the correct amount of tax it is liable for the correct amount that it was required to withhold.
Form 4670 is used to submit Forms 4669, Statement of Payments Received, to the IRS. The Internal Revenue Code and regulations provide that a
payor can be relieved of the payment of some taxes provided the payor can show that the payee has reported the payments and paid the tax. Form
4669 is used to show that the payee has reported the payments and paid the tax.
Note: The payor is still liable for any penalty or addition to the tax that applies to the failure to deduct and withhold.
General Instructions
You should obtain a separate Form 4669 from each payee for each year relief is requested. After you obtain the Forms 4669, complete and sign a Form
4670 for each tax form and each tax year for which you are requesting relief. Attach Forms 4669, any examination reports, and any amended return to
Form 4670. Retain copies for your records.
• For payments subject to Income Tax Withholding, Backup Withholding, or Additional Medicare Tax, attach a copy of the examination report. If the
tax for which relief is requested has been paid, you must also complete the appropriate adjusted return or claim form (Form 941-X, Form 943-X,
Form 944-X, Form 945-X or Form CT-1X).
• For payments to foreign persons subject to withholding tax, attach a copy of the Form 4549/4549-A (Income Tax Examination Changes).
Important: It is to your advantage to submit this form and the required attachments at the earliest possible date, to avoid collection action.
Section 3402 requires employers to withhold income tax on payments of wages, including reclassified wages and fringe benefits subject to federal
income tax withholding. Employers are also responsible under sections 3102 and 3202 for withholding a 0.9% Additional Medicare Tax from wages or
compensation paid to an employee in excess of $200,000 in a calendar year. For more information on income tax withholding or Additional Medicare
Tax, see Publication 15 (Circular E), Employer’s Tax Guide, the Instructions for Form 8959, or visit
Catalog Number 23290O
(Rev. 8-2015)


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