Form 4669 - Statement Of Payments Received
Download a blank fillable Form 4669 - Statement Of Payments Received in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 4669 - Statement Of Payments Received with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
14669
Department of the Treasury - Internal Revenue Service
OMB Number
Form
Statement of Payments Received
1545-0364
(December 2014)
Part 1 - Tell us about the payments that were made
(To be completed by payor)
1. Name and address of payee
2. Payee's Taxpayer Identification Number
3. Calendar year
4. Name and address of payor
5. Payor's Taxpayer Identification Number
6. Amount of payments
$
a. Payments subject to Income Tax Withholding
$
b. Payments subject to Backup Withholding
$
c. Payments to Foreign Persons subject to Withholding Tax
$
d. Payments subject to Additional Medicare Tax Withholding
Part 2 - Tell us where the payments were reported and that the taxes were paid (To be completed by payee)
7. Name(s) and address as shown on the payee's tax return
8. The payments shown above on line 6a, 6b, or 6c are reported on my return and the taxes due have been paid in full as shown on
a. Line
on my Form
return for tax year
b. Schedule
on my Form
return for tax year
9. The payments shown above on line 6d are either
a.
Reported on my return on Line
on Form 8959 attached to my Form 1040 return for tax year
.
The taxes due on the return have been paid in full.
OR
b.
I was not liable for Additional Medicare Tax for tax year
because I filed a joint tax return with my spouse and
did not have total Medicare wages and tips and self-employment income of more than $250,000 or total railroad retirement
(RRTA) compensation of more than $250,000.
Part 3 - Sign here (To be completed by payee)
Under penalties of perjury, I declare that I have examined this form and, to the best of my knowledge and belief it is true, correct, and
complete.
Payee name
Payee title
Best daytime telephone number
(print)
(print)
Payee signature
Date
(MM-DD-YYYY)
4669
Catalog Number 41877Z
Form
(Rev. 12-2014)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial