Form 4219 Statement of Liability of Lender, Surety, or Other Perso

Form

Statement of Liability of Lender, Surety, or
Other Person for Withholding Taxes

4219

(Rev. January 2013)

OMB Number
1545-XXXX

Under Section 3505 of the Internal Revenue Code
(Please file this form in duplicate)

Information relating to Employer (Borrower) for whom wages paid or to whom funds supplied
1. Name of employer (as used on employment tax return)
2. Employer identification number

3. Trade name, if other than above

4. Date quarter ended (See item 4 of
instructions)

5. Address (Number, street, city, State, ZIP code)
Information about the person making the wage payments for, or supplying funds to, the above Employer (Borrower)
6. Name

7. Address (Number, street, city, State, ZIP code)

8. Identification of project(s), contract(s), etc., for which wages paid or funds supplied

Computation of
Liability for
Withholding Taxes
on Wages Paid
Directly to
Employees of
Borrower
Computation of
Liability for
Withholding Taxes
on Funds Supplied
for Specific
Purpose of Paying
Wages

9. Amount of employees taxes required to be
withheld by employer

a. Income tax
b. FICA tax
c. Railroad retirement tax

10. Total taxes required to be withheld by employer (Sum of Items 9a, b, and c)
11. Portion of Item 10 paid by employer
12. Liability for withholding taxes (Item 10 minus Item 11. Enter here and in Item 19.)
13. Amount supplied to employer for paying wages
$
a. Income tax
14. Amount of employee taxes required to be
b. FICA tax
withheld by employer
c. Railroad retirement tax
15. Total taxes required to be withheld by employer (Sum of Items 14a, b, and c)
16. Portion of Item 15 paid by employer
17. Balance of Item 15 not paid by employer (Item 15 minus Item 16)
18. Liability for withholding taxes (The lesser of Item 17 or 25 percent of Item 13. Enter here
and in Item 20.)

Total
Liability

19. Liability where wages paid directly to employees (Item 12)
20. Liability where funds supplied for payment of wages (Item 18)
21. Total liability for withholding taxes (Sum of Items 19 and 20)
22. Interest liability
23. Total liability (Sum of Items 21 and 22)

Under the penalties of perjury, I declare that I have examined this statement, and to the best of my knowledge and belief, it is true, correct,
and complete. Declaration of preparer (other than taxpayer) is based on all information of which he/she has any knowledge.

Signature of lender, surety, or other person

Title

Date

Signature of preparer, if other than above

Title

Date

Form 4219 (Rev. 1-2013)

Catalog Number 41456S

www.irs.gov

Department of the Treasury—Internal Revenue Service

Page 2

Form 4219 (Rev. 1-2013)

General Instructions
Who must file Form 4219—File this form if you are a lender, surety, or
other person who, by reason of having paid wages directly to employees
of another employer, or having supplied funds for the purpose of paying
wages to employees of another employer, has incurred liability under
section 3505 of the Internal Revenue Code for taxes required to be
withheld. If you are an employer within the meaning of code section 3401
(d)(1) or (d)(2) and the related regulations, do not use Form 4219 to
report income tax withholding.
Internal Revenue Code—Section 3505(a) provides that if a lender,
surety, or other person pays wages directly to employees of another
employer, or to an agent of such employees, the lender, surety, or other
person is liable for payment to the United States of a sum equal to the
following taxes (and interest) required to be withheld from such wages by
the other employer:
(a) FICA tax required to be withheld under section 3102;
(b) Railroad retirement tax required to be withheld under section
3202; and
(c) Income tax required to be withheld under section 3402.
Section 3505(b) provides that if a lender, surety, or other person supplies
funds to or for the account of another employer for the specific purpose
of paying wages of the employees of the other employer, with actual
notice or knowledge that the employer does not intend, or will not be
able, to make timely payment or deposit of the above taxes required to
be withheld by the employer, the lender, surety, or other person is liable
for payment to the United States of a sum equal to the taxes, plus any
interest, that are not paid by the employer. However, the liability under
section 3505(b) cannot exceed 25% of the amount supplied specifically
for the purpose of paying of wages. Section 3505(b) does not apply to
ordinary working capital loans to employers, even though it is known that
part of the funds advanced will be used to pay wages.

For purposes of section 3505(b), an organization is deemed to have
actual notice or knowledge of any fact relating to a transaction from the
time that fact is brought to the attention of the individual conducting the
transaction, and in any event from the time that fact would have been
brought to the individual's attention if the organization had exercised due
diligence, as defined in Code section 6323(i)(1).
The liability under section 3505 does not extend to the portion of the
employer's taxes imposed under the Federal Insurance Contributions Act
or the Railroad Retirement Tax Act. Under Section 3505, the employer
remains liable for withholding taxes not paid by the lender, surety, or
other person, and is required to file an employment tax return for such
wages paid by the employer, a lender, surety, or other person, and
furnish statements to employees of taxes withheld.
Separate Form 4219 for each employer and each calendar quarter—
A separate Form 4219 should be submitted, in duplicate, for each
employer and for each calendar quarter for which liability under section
3505 is incurred.
Where to file—File Form 4219 with the office of the Internal Revenue
Service where the employer for whom wages were paid or funds were
supplied files Federal employment tax returns.
Payment—Include with each Form 4219 a remittance (check or money
order) for the amount shown in item 23, payable to the United States
Treasury. Payment of the withholding taxes shown on Form 4219 by
either the employer or the lender, surety, or other person satisfies the
liability. If neither the employer nor the lender, surety, or other person
pays these taxes, the U.S. Government may collect the unpaid amount
by appropriate civil action. To avoid the accumulation of interest, make
the payment on or before the due date of the employer's (borrower's)
Federal employment tax return.

Specific Instructions
Item 4. Enter the last day of the calendar quarter during which the wages
were actually paid to the employees of another employer. If funds were
supplied to the employer for payment of wages, show the last day of the
calendar quarter during which the wages were actually paid by the
employer.
Item 9. Enter in items 9a, b, and c the amounts of employee taxes
required to be withheld as if the wages were paid by the employer.

Item 14. Enter in items 14a, b, and c the amounts of employee taxes
required to be withheld by the employer from wages paid during this
quarter with funds supplied for that specific purpose.
Item 22. If the liability is paid after the due dates of the employer's
Federal employment tax return, interest will be charged at the annual
rate established under Internal Revenue Code section 6621(a) subject to
adjustments as provided in section 6621(b).

Item 13. Enter the gross amount (without reduction for withholding taxes)
supplied to the employer for the specific purpose of paying wages which
were actually paid during this quarter.

Privacy Act and Paperwork Reduction Act Notice
We ask for the information on Form 4219 to carry out the Internal Revenue laws
of the United States. We need it to figure and collect the right amount of tax.
Subtitle C, Employment Taxes, of the Internal Revenue Code imposes employment
taxes on wages, including income tax withholding. Form 4219 is used to determine
if you as a lender, surety or other person who paid wages directly to employees of
another employer, has incurred liability under section 3505 for taxes required to be
withheld. Section 6011 requires you to provide the requested information if the tax
is applicable to you. Section 6109 requires you to provide your identification
number. If you fail to provide this information in a timely manner, or provide false or
fraudulent information, you may be subject to penalties and interest.
You are not required to provide the information requested on a form that is
subject to the Paperwork Reduction Act unless the form displays a valid OMB
control number. Books and records relating to a form or its instructions must be
retained as long as their contents may become material in the administration of any
Internal Revenue law.
Generally, tax returns and return information are confidential, as required by
section 6103. However, section 6103 allows or requires the IRS to disclose or give
the information shown on your tax return to others as described in the Code. For

Form 4219 (Rev. 1-2013)

Catalog Number 41456S

example, we may disclose your tax information to the Department of Justice for civil
and criminal litigation, and to cities, states, the District of Columbia, and U.S.
commonwealths and possessions for use in administering their tax laws. We may
also disclose this information to other countries under a tax treaty, to federal and
state agencies to enforce federal nontax criminal laws, or to federal law
enforcement and intelligence agencies to combat terrorism.
The time needed to complete and file Form 4219 will vary depending on
individual circumstances. The estimated average time is: Recordkeeping, 11 hr.;
Learning about the law or the form, 50 min.; Preparing, copying, assembling,
and sending the form to the IRS, 1 hr.
If you have comments concerning the accuracy of these time estimates or
suggestions for making Form 4219 simpler, we would be happy to hear from you.
You can email us at [email protected]. Enter “Form 4219” on the subject line. Or
write to: Internal Revnue Service, Tax Products Coordinating Committee, SE:W:
CAR:MP:T:M:S, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224. Do
not send Form 4219 to this address. Instead, see Where to File? in the instructions
for Form 4219.

www.irs.gov

Department of the Treasury—Internal Revenue Service