Template from tincompliance.com. A letter asking a payee to sign Form 4669 so the payer can be relieved of backup withholding tax under IRC 3402(d) (applied by IRC 3406(h)(10)). The IRS backup withholding unit accepts a complete, signed Form 4669 as prima facie evidence (IRM 4.19.26.10.7.13.1) but rejects one with a truncated TIN, more than one tax year, an amount that does not tie to the IRS's list, no identification of the form, schedule and line, or an altered jurat (IRM 4.19.26.10.7.13.2). Relief covers the tax only, not penalties or interest. Not legal advice.
[Company name]
[Address]
[Date]
[Payee name]
[Payee address]
Re: Request to complete Form 4669 for payments made to you in [year]
Dear [payee name],
During [year], [Company] paid you $[amount] for [services / interest / rents / other], reported to the IRS on Form [1099-NEC / other]. Because we did not have your taxpayer identification number on file at the time of those payments, federal law required us to withhold 24% federal income tax from them, and we did not. The IRS has [asked us to account for / assessed] that withholding.
The tax law allows us to be relieved of that liability if you reported the payments on your own federal income tax return and paid the tax due. To document that, the IRS uses Form 4669, Statement of Payments Received. We have completed the payer portion (lines 1 through 6). We ask that you:
- Check that the amount on line 6 matches what you received from us in [year]. If it does not, please tell us before signing rather than changing the form; the amount must match the IRS's records exactly.
- Complete Part 2: the form (for example Form 1040 or 1120), schedule, line and tax year on which you reported this income.
- Provide your full taxpayer identification number where indicated. The IRS does not accept a truncated number on this form.
- Sign and date Part 3 without altering the printed declaration, and print your name, title (if a business) and phone number.
- Return the signed form to us by [date] in the enclosed envelope or by secure upload at [link].
Please note that Form 4669 is signed under penalties of perjury and states that you reported the income and paid the tax. The IRS may review that statement. If you did not report the income, please do not sign the form; contact us instead so we can discuss the withholding.
This request does not affect the amount you were paid. It allows us to show the IRS that the tax on these payments has already been paid, so that it is not collected a second time.
Questions: [name / department], [phone], [email]. Thank you for your help.
[Signature block]
Enclosures: Form 4669 (payer portion completed); return envelope