IRS Form 4669, the Statement of Payments Received, is a document a payer asks you to sign to confirm that you already reported certain income on your tax return and paid the tax on it. You do not file it with your own return, and you are not required to sign it. If you do sign, you are making a sworn statement that the payer can then use to ask the IRS for relief from withholding taxes the payer failed to collect from you.1Internal Revenue Service. Form 4669 – Statement of Payments Received
Why a Payer Is Asking You to Sign
When an employer or other payer fails to withhold income tax, Social Security tax, or Medicare tax from payments to you, the IRS can hold that payer liable for the full amount that should have been withheld. The tax code gives the payer an escape: if the person who received the payments already reported the income and paid the matching tax, the IRS will not collect the same tax twice.2Office of the Law Revision Counsel. 26 USC 3402 – Income Tax Collected at Source3Office of the Law Revision Counsel. 26 USC 3102 – Deduction of Tax From Wages Form 4669 is how the payer proves that is what happened.
The most common trigger is worker misclassification. A company treated you as an independent contractor, paid you without withholding, then got audited. The IRS reclassified the payments as wages, and the company now owes withholding taxes it never collected. To avoid paying out of pocket, the company asks you to complete Form 4669 showing you handled the tax on your own return. The form specifically covers reclassified wages and fringe benefits subject to federal income tax withholding, along with backup withholding, withholding on payments to foreign persons, and Additional Medicare Tax withholding.1Internal Revenue Service. Form 4669 – Statement of Payments Received
You Do Not Have to Sign It
The Privacy Act notice on the form says plainly: “You are not required to provide this information to the payor.”1Internal Revenue Service. Form 4669 – Statement of Payments Received Refusing to sign creates no penalty or tax consequence for you. The notice adds that refusal “may delay or prevent the payor’s request for relief.” That is a cost to the payer, not to you.
Cooperating is reasonable when the certification would be truthful. Signing costs you nothing if you really did report the income and really did pay the tax. Where it turns into a serious problem is signing when you did not. The form is signed under penalties of perjury, and providing false information can bring a felony conviction with a fine of up to $100,000 and up to three years in prison.4Office of the Law Revision Counsel. 26 USC 7206 – Fraud and False Statements
If a former employer surfaces years after the fact asking you to sign, pull your old return before you agree to anything. The amounts on the form need to match what you actually reported.
Check Part 1 Before You Touch the Form
Part 1 is completed by the payer, not you. Your job is to read it carefully. The payer fills in:
- Your name, address, and taxpayer identification number (Lines 1 and 2)
- The calendar year the payments were made (Line 3)
- The payer’s name, address, and Employer Identification Number (Lines 4 and 5)
- The dollar amounts of payments, broken into four categories on Lines 6a through 6d: payments subject to income tax withholding, payments subject to backup withholding, payments to foreign persons subject to withholding tax, and payments subject to Additional Medicare Tax withholding
Compare every dollar amount against your own records before going further. If the payer lists $45,000 and your records show $38,000, stop and resolve the discrepancy. A separate Form 4669 is required for each payee and each tax year, so verify the year on the form matches the return you reported the income on.1Internal Revenue Service. Form 4669 – Statement of Payments Received
Filling Out Part 2
Part 2 is where you tell the IRS exactly where the payments showed up on your return.1Internal Revenue Service. Form 4669 – Statement of Payments Received
Line 7 asks for your name and address as they appeared on your tax return. If you have moved since filing, use the address from the return rather than your current one.
Lines 8a and 8b are the core of the form. You identify the form number, tax year, and either the line number (8a) or the schedule (8b) where you reported the payments. If you received the payments as an independent contractor and reported them on Schedule C, you would write “Schedule C” on Line 8b along with “Form 1040” and the tax year. If instead you reported them as wages on Line 1 of Form 1040, use Line 8a. Complete only the one that matches how you actually reported the income.
Additional Medicare Tax: Lines 9a and 9b
If the payer entered an amount on Line 6d, you also need to address Lines 9a and 9b. The Additional Medicare Tax is an extra 0.9% that applies to wages and self-employment income above $200,000 for individual filers or $250,000 for married couples filing jointly.5Internal Revenue Service. 2026 Publication 926
Check Line 9a if you reported the payments on Form 8959 (the Additional Medicare Tax form) attached to your return and paid the tax in full. Check Line 9b if you were not liable for the Additional Medicare Tax at all, for example because your combined Medicare wages and self-employment income on a joint return did not exceed $250,000.1Internal Revenue Service. Form 4669 – Statement of Payments Received
Signing Part 3
Part 3 is the certification. By signing, you declare under penalties of perjury that the information is true, correct, and complete, and that the taxes shown on your return have been paid in full.1Internal Revenue Service. Form 4669 – Statement of Payments Received You print your name, add a title if applicable, a daytime phone number, your signature, and the date.
Treat this as a sworn statement, not a routine acknowledgment. If you reported the income but still owe a balance on that return, the certification is not accurate; the tax has not been paid in full. Clear any outstanding balance first, or decline to sign until you can do so truthfully.
Return the signed form to the payer, not to the IRS. Keep a copy for your records.
What Your Signature Actually Does for the Payer
Even when the IRS grants relief based on your signed form, the payer does not walk away clean. The statute is explicit: relief from the withholding tax itself “shall in no case relieve the employer from liability for any penalties or additions to the tax otherwise applicable” for the failure to withhold.2Office of the Law Revision Counsel. 26 USC 3402 – Income Tax Collected at Source The same limitation applies to Social Security and Medicare tax relief3Office of the Law Revision Counsel. 26 USC 3102 – Deduction of Tax From Wages and to withholding on payments to foreign persons.6eCFR. 26 CFR 1.1463-1 – Tax Paid by Recipient of Income
The payer avoids double collection of the withholding tax but can still owe failure-to-deposit penalties, interest, and other additions. If a payer is pressuring you to sign by claiming the form “makes the whole problem go away,” that overstates what it does for them. Your signature also does not change your own tax situation in any way. If you reported the income correctly, signing confirms what you already did and nothing more.
Form 4669 Is Not Form 4852
The two forms sound similar and solve completely different problems. Form 4852 is a substitute for a missing or incorrect W-2 or 1099-R; you file it with your own return when an employer will not provide the right documents, and you estimate your income and withholding from your records.7Internal Revenue Service. About Form 4852, Substitute for Form W-2, Wage and Tax Statement, or Form 1099-R Form 4669 is not filed with the IRS at all; it goes back to the payer who asked for it, and it confirms income you already reported rather than reporting income for the first time. If you need to file your return without a W-2, you want Form 4852. If a current or former payer handed you Form 4669, you are in the situation this page describes.