Certified Professional Employer Organization Customer Reporting Agreement

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8973
Certified Professional Employer Organization/Customer
Form
Reporting Agreement
OMB No. 1545-2266
(May 2017)
Department of the Treasury — Internal Revenue Service
Read the separate instructions before you complete Form 8973.
Part 1:
Why are you filing this form?
A service contract started on
/
/
between the customer reported in Part 2 and the CPEO reported in Part 3.
A service contract ended on
/
/
between the customer reported in Part 2 and the CPEO reported in Part 3.
Correcting a previously filed Form 8973.
Part 2:
Customer Information
1
Customer’s employer identification number (EIN)
2
Customer’s name (not your trade name)
Customer’s trade name (if any)
3
4
Address
Number
Street
Suite or room number
City
State
ZIP code
Foreign country name
Foreign province/county
Foreign postal code
CPEO reports all wages/
CPEO reports some
Identify forms that the CPEO will file reporting wages or compensation paid to
5
compensation paid to
wages/compensation
employees performing services for the customer. Check all that apply.
employees
paid to employees
Form 940, 940-PR (Employer’s Annual Federal Unemployment (FUTA) Tax Return)
Form 941, 941-PR, 941-SS (Employer’s QUARTERLY Federal Tax Return)
Form 943, 943-PR (Employer’s Annual Federal Tax Return for Agricultural
Employees)
Form CT-1 (Employer’s Annual Railroad Retirement Tax Return)
Part 3:
CPEO Information
6
CPEO’s employer identification number (EIN)
7
CPEO’s name (not your trade name)
CPEO’s trade name (if any)
8
9
Address
Number
Street
Suite or room number
City
State
ZIP code
8973
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(5-2017)
Cat. No. 37796R

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