Form 14196 - Filing Statement - 2010
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1Department of the Treasury — Internal Revenue Service
14196
Form
Filing Statement
(November 2010)
Complete the following information:
Establishment name
Establishment address
Employer Identification Number
Daytime telephone number (including area code)
(
)
Complete and sign the following statement:
I,
, under penalties of perjury, do certify that I did not meet
(Print Name and Title)
any of the Requirements, as explained in this letter, for filing Form 8027, Employer’s Annual Information Return of Tip
Income and Allocated Tips, for the year
.
I did not meet the requirements because
NOTE: If you were not required to file because you did not employ more than 10 employees who together worked more
than 80 hours on a typical business day, please send us a completed copy of the Worksheet for Determining Whether to
File Form 8027 (included in the instructions for completing the Form 8027 return), when you send us the completed
statement.
Signature and Title
Date
Catalog Number 56047X
Form
14196
(Rev. 11-2010)
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