Form 4219 - Statement Of Liability Of Lender, Surety, Or Other Person For Withholding Taxes
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1
2Statement of Liability of Lender, Surety, or
4219
OMB Number
Form
Other Person for Withholding Taxes
1545-2254
(Rev. May 2014)
Under Section 3505 of the Internal Revenue Code
(Please file this form in duplicate)
Information relating to Employer (Borrower) for whom wages paid or to whom funds supplied
1. Name of employer
2. Employer identification number
(as used on employment tax return)
3. Trade name, if other than above
4. Date quarter ended
(See item 4 of
instructions)
5. Address
(Number, street, city, State, ZIP code)
Information about the person making the wage payments for, or supplying funds to, the above Employer (Borrower)
6. Name
7. Address (Number, street, city, State, ZIP code)
8. Identification of project(s), contract(s), etc., for which wages paid or funds supplied
a. Income tax
Computation of
9. Amount of employees taxes required to be
b. FICA tax
Liability for
withheld by employer
Withholding Taxes
c. Railroad retirement tax
on Wages Paid
10. Total taxes required to be withheld by employer
(Sum of Items 9a, b, and c)
Directly to
Employees of
11. Portion of Item 10 paid by employer
Borrower
12. Liability for withholding taxes
(Item 10 minus Item 11. Enter here and in Item 19.)
13. Amount supplied to employer for paying wages
$
a. Income tax
14. Amount of employee taxes required to be
Computation of
b. FICA tax
withheld by employer
Liability for
c. Railroad retirement tax
Withholding Taxes
on Funds Supplied
15. Total taxes required to be withheld by employer
(Sum of Items 14a, b, and c)
for Specific
16. Portion of Item 15 paid by employer
Purpose of Paying
Wages
17. Balance of Item 15 not paid by employer
(Item 15 minus Item 16)
18. Liability for withholding taxes
(The lesser of Item 17 or 25 percent of Item 13. Enter here
and in Item 20.)
19. Liability where wages paid directly to employees
(Item 12)
20. Liability where funds supplied for payment of wages
(Item 18)
Total
21. Total liability for withholding taxes
(Sum of Items 19 and 20)
Liability
22. Interest liability
23. Total liability
(Sum of Items 21 and 22)
Under the penalties of perjury, I declare that I have examined this statement, and to the best of my knowledge and belief, it is true, correct,
and complete. Declaration of preparer (other than taxpayer) is based on all information of which he/she has any knowledge.
Signature of lender, surety, or other person
Title
Date
Signature of preparer, if other than above
Title
Date
4219
Form
(Rev. 5-2014)
Catalog Number 41456S
Department of the Treasury—Internal Revenue Service
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