Request For Relief Of Payment Of Certain Withholding Taxes (Page 2 of 2) in pdf

Page 2

Under section 3406, in the case of a reportable payment a payor is required to withhold a tax equal to the applicable percentage of the reportable

payment in certain cases (e.g., if the payee fails to furnish the payee’s taxpayer identification number in the manner required). This withholding is

referred to as “backup withholding.” For more information on backup withholding see Publication 1281, Backup Withholding for Missing and Incorrect

Name/TIN(s), or visit and enter the term “backup withholding” in the search box.

Withholding agents may be required to withhold tax on certain payments made to a foreign person (individual or entity) subject to withholding tax under

chapters 3 and 4. For more information see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities. Regulations section

1.1441-1(b)(7) provides that a withholding agent may provide a Form 4669 to establish the amount of tax, if any, actually paid by or for the beneficial

owner of the income

Where to File

If Form 4670 is related to an examination that is still ongoing or has ended in the past 30 days, submit Form 4670 with required attachments to the IRS

Examiner with whom you are working.

If Form 4670 is related to an examination that concluded more than 30 days ago, or is not related to an examination, submit Form 4670 with required

attachments to the address provided below:

IF you are in...

THEN use this address...

Special filing address for exempt organizations; federal, state, and local governmental entities; and

Department of the Treasury

Indian tribal governmental entities; regardless of location

Internal Revenue Service

Ogden, UT 84201-0005

No legal residence or principal place of business in any state or if Form 4670 is related to Form

Internal Revenue Service

1042

P.O. Box 409101

Ogden, UT 84409

Connecticut, Delaware, District of Columbia, Florida, Georgia, Illinois, Indiana, Kentucky, Maine,

Department of the Treasury

Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina,

Internal Revenue Service

Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Vermont, Virginia, West Virginia,

Cincinnati, OH 45999-0005

Wisconsin

Alabama, Alaska, Arizona, Arkansas, California, Colorado, Hawaii, Idaho, Iowa, Kansas, Louisiana,

Department of the Treasury

Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Mexico, North Dakota,

Internal Revenue Service

Oklahoma, Oregon, South Dakota, Texas, Utah, Washington, Wyoming

Ogden, UT 84201-0005

Specific Instructions

Employer Identification Number, Name, and Address

Type or print your employer identification number (EIN), name, and address in the spaces provided. Do not use your social security number (SSN) or

individual taxpayer identification number (ITIN). Generally, enter the business (legal) name you used when you applied for your EIN on Form SS-4,

Application for Employer Identification Number.

Tax Return and Tax Year Covered

Check the form type and enter the tax year for which relief from payment of taxes is requested. For example, if tax was reported on your Forms 941 for

tax year 2013, check the box for Form 941 and enter 2013 in the space provided.

Do not enter more than one form type or tax year on Form 4670. If more than one tax year or more than one tax form was examined, submit a separate

Form 4670 for each form type and tax year for which you are requesting relief. Each Form 4670 must have attached the required documentation

corresponding to the form type and tax year you specify on Form 4670. See General Instructions above for the required documentation.

Number of Statements Attached

In the space provided, enter the number of Forms 4669 you are attaching to your Form 4670.

Signature

You must complete all sections of Form 4670 and sign it. If you do not sign, your Form 4670 will be returned to you for your signature.

Form 4670 must be signed by one of the following:

• Sole proprietorship—The individual who owns the business.

• Corporation (including a limited liability company (LLC) treated as a corporation)—The president, vice president, or other principal officer duly

authorized to sign.

• Partnership (including an LLC treated as a partnership) or unincorporated organization—A responsible and duly authorized member, partner, or

officer having knowledge of its affairs.

• Single member LLC treated as a disregarded entity for federal income tax purposes—The owner of the LLC or a principal officer duly authorized to

sign.

• Trust or estate—The fiduciary.

Form 4670 may also be signed by a duly authorized agent of the taxpayer if a valid power of attorney has been filed.

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 you

are eligible for relief from payment of tax withholding and the amount, if any, of relief. You are not required to apply for relief from payment of tax

withholding; however, if you do apply you are required to give us the information requested on this form. We need it to determine your eligibility for relief

and to figure and collect the right amount of tax. Section 6109 requires you to provide your identification number. Failure to provide the information we

ask for may delay or prevent processing of your request; providing false or fraudulent information may subject you to penalties.

4670

Catalog Number 23290O

Form

(Rev. 8-2015)