This form was created in response to
the Hiring Incentives to Restore Employment (HIRE) Act, which was
signed on March 18, 2010. The form was developed as a template for
the convenience of employers who must collect affidavits from
qualifying employees. The form is not filed, rather an employer
must retain the affidavit in order to justify claiming certain HIRE
Act benefits. A model form is needed as soon as possible so that
employers can begin confidently claiming payroll exemptions. The
useful life of the form is only from March 18, 2010 to December 31,
2010.
Public Law 111-147,
signed March, 18, 2010, provides current tax benefits in the form
of a payroll tax exemption for qualified employers. In order to
receive these benefits, the employer must acquire and retain with
its records an affidavit or similar statement from a qualified
employee. This Form W-11 is an acceptable affidavit that may be
used by an employer directly or as a model for its own similar
statement. The information collected on Form W-11 is not filed with
or reported to the IRS; instead, the employer is required to retain
the affidavit with its payroll and tax records for future
production if audited by the IRS.
Public Law 111-147, signed
March, 18, 2010, provides current tax benefits in the form of a
payroll tax exemption for qualified employers. In order to receive
these benefits, the employer must acquire and retain with its
records an affidavit or similar statement from a qualified
employee. This Form W-11 is an acceptable affidavit that may be
used by an employer directly or as a model for its own similar
statement. The information collected on Form W-11 is not filed with
or reported to the IRS; instead, the employer is required to retain
the affidavit with its payroll and tax records for future
production if audited by the IRS. The creation of this affidavit
has resulted in an increase in the estimated number of responses by
100,000 and a total estimated burden increase of 227,000
hours.
$50,000
No
No
Uncollected
Uncollected
No
Uncollected
Jason Healey 2022830386
No
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.
Form W-11 Form W-11 - Hiring Incentives to Restore Employment (HIRE) Act Employee Affidavit
ombat2.doc
Supporting Statement.pdf
Form W-11 - Hiring Incentives to Restore Employment (HIRE) Act Employee Affidavit