Fillable Form 4669 - Statement Of Payments Received (Page 3 of 3) in pdf

Page 3

Privacy Act and Paperwork Reduction Act Notice

We ask for the information on this form to carry out the Internal Revenue laws of the United States. Subtitle C, Employment Taxes, of the

Internal Revenue Code requires tax withholding on wages and railroad retirement (RRTA) compensation. Additionally, section 3406 requires

backup withholding on certain payments, and chapters 3 and 4 require tax withholding on certain payments to foreign persons. This form is

used to determine whether the payor is eligible for relief from payment of tax withholding based on payments made to you. You are not required

to provide this information to the payor. Not providing this information, or providing incomplete information, may delay or prevent the payor’s

request for relief. If you choose to provide this information, providing false or fraudulent information may subject you to penalties.

Generally, tax returns and return information are confidential, as required by section 6103. However, section 6103 allows or requires the IRS to

disclose or give the information to others as described in the Code. We may disclose your tax information to the Department of Justice for civil

and criminal litigation, and to cities, states, the District of Columbia, and U.S. commonwealths and possessions to administer their tax laws. We

may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or

to federal law enforcement and intelligence agencies to combat terrorism.

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 relating to a form or instructions must be retained as long as their contents may become material

in the administration of any Internal Revenue law. The time needed to complete and file this form will vary depending on individual

circumstances. The estimated burden for individual taxpayers filing this form is approved under OMB control number 1545-0364 and is included

in the estimates shown in the instructions for their individual income tax return. The estimated burden for all other taxpayers who file this form is

shown below.

Recordkeeping: 5 min.

Learning about the law or the form: 4 min.

Preparing the form: 4 min.

Copying, assembling, and sending the form: 2 min.

If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear

from you. You can send your comments to Click on “More Information” and then click on “Give us feedback on forms

and publications”. Or you can send your comments to Internal Revenue Service, Tax Forms and Publications Division, 1111 Constitution Ave.

NW, IR-6526, Washington, DC 20224. Do not send Form 4669 to this address. Instead, give Form 4669 to the payor.

4669

Catalog Number 41877Z

Form

(Rev. 12-2014)

Form 4669 - Statement Of Payments Received Page 3