Form W-11 - Hiring Incentives To Restore Employment (Hire) Act Employee Affidavit
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1W-11
Hiring Incentives to Restore Employment (HIRE) Act
Form
(
, 2010)
Employee Affidavit
Department of the Treasury
Internal revenue Service
To be completed by new employee. Affidavit is not valid unless employee signs it.
I certify that I have not been employed for more than 40 hours during the 60-day period ending on the date I am employed by this
employer.
Your name _________________________________
Your social security number ____|_____|_____
Name of employer ________________________________________
Date of hire _____/____/_____
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 Employer:
60-day period ending on the date the
and profits interests of the employee.
individual begins employment;
● is not employed by the qualified employer to
Please have each employee who is a qualified
(The last requirement is pursuant to a provision in
employee sign the affidavit above. Completion and
the statute that provides that a qualified employee is
replace another employee of the employer
execution of the affidavit by the qualified individual is
unless the other employee separated from
not an individual described in Internal Revenue
one of the requirements for the employer to claim
employment voluntarily or for cause; and
Code section 51(i)(1) (applied by substituting
● is not a child or a descendant of a child, a
the benefits of the HIRE Act.
“qualified employer” for “taxpayer” each place it
sibling or stepsibling, father or mother or an
appears).)
A “qualified employee” is an individual who:
ancestor of either, stepparent, niece or
For situations where the employer is an estate or
nephew, aunt or uncle, or an in-law of the
● begins employment with a qualified employer
trust, please see Internal Revenue Code section 51
employer; also the employee is not related to
after February 3, 2010, and before January
(i)(1) and Internal Revenue Code section 152(d)(2)
anyone owning more than 50% of the
1, 2011;
outstanding stock or capital and profits
for more details.
● certifies by signed affidavit, under penalties
interests of the employer or is a dependent
of perjury, that he or she has not been
of the employer or of anyone owning more
employed for more than 40 hours during the
than 50% of the outstanding stock or capital
W-11
Cat. No. 10744F
(
, 2010)
Form
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