Supporting Statement

SUPPORTING STATEMENT
1. CIRCUMSTANCES NECESSITATING COLLECTION OF INFORMATION
The information collected on Form W-11 will be used to partially confirm that a qualified employer has procured the
services of a qualified individual, as defined in amendments made to 26 USC 3111 by section 101 of P.L. 111-147. An
employer who hires a qualified individual may be able to claim a special employment tax exemption and business
credit for retaining the qualified individual. These two benefits are found in sections 101 and 102 of P.L. 111-147.

2. USE OF DATA
The information collected on Form W-11 is not reported to the IRS; instead Form W-11 or a similar statement must be
kept by the qualified employer in case of audit. The affidavit is used to ensure entitlement to certain tax benefits
provided by sections 101 and 102 of P.L. 111-147. The date of hire and employer name information will be used to
confirm that the affidavit was made during the applicable period to the employer that is claiming those tax benefits.

3. USE OF IMPROVED INFORMATION TECHNOLOGY TO REDUCE BURDEN
We have no plans at this time to offer electronic filing because of the low volume compared to the cost of electronic
enabling.

4. EFFORTS TO IDENTIFY DUPLICATION
We have attempted to eliminate duplication within the agency wherever possible.

5. METHODS TO MINIMIZE BURDEN ON SMALL BUSINESSES OR OTHER SMALL ENTITIES
Not applicable.

6. CONSEQUENCES OF LESS FREQUENT COLLECTION ON FEDERAL PROGRAMS OR
POLICY ACTIVITIES
Not applicable.

Form 14029 (Rev. 4-2009) Catalog Number 51944B Page 4

Department of the Treasury–Internal Revenue Service

7. SPECIAL CIRCUMSTANCES REQUIRING DATA COLLECTION TO BE INCONSISTENT
WITH GUIDELINES IN 5 CFR 1320.5(d)(2)
Not applicable.

8. CONSULTATION WITH INDIVIDUALS OUTSIDE OF THE AGENCY ON AVAILABILITY
OF DATA, FREQUENCY OF COLLECTION, CLARITY OF INSTRUCTIONS AND FORMS,
AND DATA ELEMENTS
Periodic meetings are held between IRS personnel and representatives of various professional groups to discuss tax
law and tax forms. During these meetings, there is an opportunity for those attending to make comments regarding the
collection requirements under this form.
We will publish a notice in the Federal Register in the near future to solicit public comments on this Notice.

9. EXPLANATION OF DECISION TO PROVIDE ANY PAYMENT OR GIFT TO RESPONDENTS
Not applicable.

10. ASSURANCE OF CONFIDENTIALITY OF RESPONSES
Generally, tax returns and tax return information are confidential as required by 26 USC 6103.

11. JUSTIFICATION OF SENSITIVE QUESTIONS
Not applicable.

12. ESTIMATED BURDEN OF INFORMATION COLLECTION
Number of
Responses
Form W-11

100,000

Time for
Recordkeeping

Time for
Reporting

Total
Hours

1 hr., 23 min

49 min.

227,000

Estimates of the annualized cost to respondents for the hour burdens shown are not available at this time.

Form 14029 (Rev. 4-2009) Catalog Number 51944B

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Department of the Treasury–Internal Revenue Service

13. ESTIMATED TOTAL ANNUAL COST BURDEN TO RESPONDENTS
Estimates of capital or start-up costs and costs of operation, maintenance, and purchase of services to provide
information are not available at this time.

14. ESTIMATED ANNUALIZED COST TO THE FEDERAL GOVERNMENT
After consultation with various functions within the Service, we have determined that the cost of developing,
printing, processing, distribution and overhead for the form is $50,000.

15. REASONS FOR CHANGE IN BURDEN
There is no change in the paperwork burden previously approved by OMB. This is a new form being submitted for
approval.

16. PLANS FOR TABULATION, STATISTICAL ANALYSIS AND PUBLICATION
Not applicable.

17. REASONS WHY DISPLAYING THE OMB EXPIRATION DATE IS INAPPROPRIATE
See attached.

18. EXCEPTIONS TO THE CERTIFICATION STATEMENT ON OMB PRA SUBMISSION FORM
Not applicable.
Note: The following paragraph applies to all of the collections of information in this submission:
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless the collection of information displays a valid OMB control number. Books or records relating to a collection of
information must be retained as long as their contents may become material in the administration of any internal
revenue law. Generally, tax returns and tax return information are confidential, as required by 26 U.S.C. 6103.

19. REASON FOR EMERGENCY SUBMISSION
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.

Form 14029 (Rev. 4-2009) Catalog Number 51944B

Page 6

Department of the Treasury–Internal Revenue Service