Form W-11 - Hiring Incentives To Restore Employment (Hire) Act Employee Affidavit

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W-11
Hiring Incentives to Restore Employment (HIRE) Act
Form
Employee Affidavit
OMB No. 1545-2173
(Rev. June 2010)
Department of the Treasury
Do not send this form to the IRS. Keep this form for your records.
Internal Revenue Service
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.
Your name
Social security number
First date of employment
/
/
Name of employer
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.
/
/
Date
Employee's signature
Instructions to the
• is not related to you. An employee is
Our legal right to ask for information is
related to you if he or she is your child or
Internal Revenue Code section 6001 and
Employer
a descendent of your child, your sibling
the purpose of the form is stated in the
or stepsibling, your parent or an
instructions. This collection of the
Section references are to the Internal
ancestor of your parent, your stepparent,
information is required to obtain certain
Revenue Code.
your niece or nephew, your aunt or
tax benefits.
Purpose of Form
uncle, or your in-law. An employee also
If you do not retain this record or give
is related to you if he or she is related to
fraudulent information, we may have to
Use Form W-11 to confirm that an
anyone who owns more than 50% of
disallow certain exemptions and credits,
employee is a qualified employee under
your outstanding stock or capital and
and you also may be charged penalties
the HIRE Act. You can use another
profits interest or is your dependent or a
and be subject to criminal prosecution.
similar statement if it contains the
dependent of anyone who owns more
This could make the tax higher or delay
information above and the employee
than 50% of your outstanding stock or
any refund. Interest may also be
signs it under penalties of perjury.
capital and profits interest.
charged.
Only employees who meet all the
If you are an estate or trust, see
The time needed to complete this form
requirements of a qualified employee
section 51(i)(1) and section 152(d)(2) for
will vary depending on individual
may complete this affidavit or similar
more details.
circumstances. The estimated average
statement. You cannot claim the HIRE
time is:
Act benefits, including the payroll tax
Do not send this form to the IRS.
!
exemption or the new hire retention
Keep it with your other payroll
Recordkeeping .
.
.
. 1 hr., 25 min.
credit, unless the employee completes
CAUTION
and income tax records.
Preparing the form
.
.
.
. 25 min.
and signs this affidavit or similar
Learning about the
statement under penalties of perjury and
Paperwork Reduction Act Notice. The
law or the form
.
.
.
.
. 24 min.
is otherwise a qualified employee.
Paperwork Reduction Act of 1980
If you have comments regarding the
requires that when we ask you for
A “qualified employee” is an employee
accuracy of this time estimate or you
who:
information we must first tell you our
have suggestions for making this form
legal right to ask for the information, why
• begins employment with you after
simpler, we would be happy to hear from
we are asking for it, and how it will be
February 3, 2010, and before January 1,
you. You can write to the Internal
used. We must also tell you what could
2011;
Revenue Service, Tax Products
happen if we do not receive it and
Coordinating Committee,
• certifies by signed affidavit, or similar
whether your response is voluntary,
SE:W:CAR:MP:T:T:SP, 1111 Constitution
statement under penalties of perjury, that
required to obtain a benefit, or
Ave. NW, IR-6526, Washington, DC
he or she has not been employed for
mandatory under the law. You are not
20224. Do not send the form to this
more than 40 hours during the 60-day
required to provide the information
address.
period ending on the date the employee
requested on a form that is subject to
begins employment with you;
the Paperwork Reduction Act unless the
Please keep this notice with your
form displays a valid OMB control
records. It may help you if we ask you for
• is not employed by you to replace
number. Books or records relating to a
other information. If you have any
another employee unless the other
form or its instructions must be retained
questions about the rules for filing and
employee separated from employment
as long as their contents may become
giving information, please call or visit any
voluntarily or for cause (including
material in the administration of any
Internal Revenue Service office.
downsizing); and
Internal Revenue law. Generally, tax
returns and return information are
confidential, as stated in Code section
6103.
W-11
Form
(Rev. 6-2010)
Cat. No. 10744F

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