Form W-11 - Hiring Incentives To Restore Employment (Hire) Act Employee Affidavit Page 3
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( R e v . J u n e 2 0 1 0 )
Department of the Treasury
Internal Revenue Service
Hiring Incentives to Restore Employment (HIRE) Act
Employee Affidavit
O M B N o . 1 5 4 5 2 1 7 3
) Do not send this form to the lRS.
this form for
records.
To be completed
by new employee. Affidavit is not valid unless employee signs it.
I certify that I have been unemployed or have not worked for anyone for more than 40 hours during the 60-day period ending on the
date I began employment with this employer.
Y o u r n a m e
Social security number )
First date of emoloymenl
Under penalties of perjury,
and complete.
Employee s signature D
Name of employer
I declare that I have examrned this affidavit and, to the best of my knowledge and belief, it is true, correcr,
D a t e >
/
/
Instructions to the
Employer
Section references are to the Internal
R e v e n u e C o d e .
Purpose of Form
Use Form W-11 to confirm that an
employee is a qualified employee under
the HIRE Act. You can use another
similar statement if it contains the
information above and the employee
signs it under penalties of perjury.
Only employees who meet all the
requirements of a qualified employee
may complete this affidavit or similar
s t a t e m e n t . Y o u c a n n o t c l a i m t h e H I R E
Aci benefits, including the payroll tax
exemption or the new hire retention
credit, unless the employee completes
and signs this affidavit or similar
statement under penalties of perjury and
is otherwise a qualified employee.
A "qualified employee" is an employee
w h o :
c begins employment with you after
February 3,2010, and before Januarv .1 ,
2 0 1 1 ;
. certifies by signed affidavit, or similar
statement under penalties of perjury, that
he or she has not been employed for
more than 40 hours during the 60-day
period ending on the date the employee
begins employment with you;
. is not employed by you to replace
another employee unless the other
employee separated from employment
voluntarily or for cause (including
d o w n s i z i n g ) ; a n d
. is not related to you. An employee is
related to you if he or she is your child or
a d e s c e n d e n t o f y o u r c h i l d , y o u r s i b l i n g
or stepsibling, your parent or an
ancestor of your parent, your stepparent,
y o u r n r e c e o r n e p h e w , y o u r a u n t o r
u n c l e , o r y o u r i n - l a w . A n e m p l o y e e a l s o
is related to you if he or she is related to
anyone who owns more than 50%o of
y o u r o u t s t a n d i n g s t o c k o r c a p i t a l a n d
profits interest or is your dependent or a
dependent of anyone who owns more
than 50% of your outstanding stock or
capital and profits interest.
lf you are an estate or trust, see
s e c t i o n 5 1 ( i ) ( 1 ) a n d s e c t i o n 1 5 2 ( d ) ( 2 ) f o r
more details.
Do not send this form to the /RS
Keep it with your other payroll
and income tax records.
Paperwork Reduction Act Notice. The
Paperwork Reduction Act of 1980
requires that when we ask you for
information we must first tell you our
legal right to ask for the information, why
we are asking for it, and how it will be
used. We must also tell you what could
happen if we do not receive it and
whether your response is voluntary,
required to obtain a benefit, or
mandatory under the law. You are not
required to provide the information
requested on a form that is subject to
the Paperwork Reduction Act unless the
form displays a valid OMB control
number. Books or records relatinq to a
form or its instructions must be reltained
as long as their contents may become
maierial in the administration of anv
Internal Revenue law. Generallv. tai
returns and return information are
confidential, as stated in Code section
6 1 0 3 .
Our legal right to ask for information is
Internal Revenue Code section 6001 and
the purpose of the form is stated in the
instructions. This collection of the
information is required to obtain cedain
tax benefits.
lf you do not retain this record or give
fraudulent information, we may have to
disallow certain exemptions and credits,
and you also may be charged penalties
and be subject to criminal prosecution.
This could make the tax higher or delay
any refund. lnterest may also be
c h a r g e d .
The time needed to complete this form
w i l l v a r y d e p e n d i n g o n i n d i v i d u a l
circumstances. The estimated averaqe
t i m e i s :
Recordkeeping
Preparing the form
Learning about the
law or the form
I h r . , 2 5 m i n .
.
. 2 5 m i n .
.
. 24 min.
lf you have comments regarding the
accuracy of this time estimate or you
have suggestions for making this form
simpler, we would be happy to hear from
you. You can write to the Internal
Revenue Service, Tax Products
Coordinating Committee,
S E : W : C A R : M P : T : T : S P ,
1 1 1 . 1 C o n s t i t u t i o n
Ave. NW, lR-6526, Washington, DC
20224. Do not send the form to this
aooress.
Please keep this notice with your
records. lt may help you if we ask you for
other information. lf you have any
questions about the rules for filinq and
g i v i n g i n f o r m a t i o n . p l e a s e c a l l o r i i s i t a n y
Internal Revenue Service offrce.
C a t . N o . 1 0 7 4 4 F
F o r m W - 1 1 ( F e v . 6 - 2 0 1 0 )
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