Form 8973 Certified Professional Employer Organization/Customer Re

Version A, Cycle 8
Fillable Fields: Font=10pt Times; Color=Black; Checkmark=Cross

February 2017
Form

8973

(December 2016)

Certified Professional Employer Organization/Customer
Reporting Agreement

OMB No. 1545-XXXX

A CPEO must also file Form 8973 to correct a previously filed Form 8973
Department of the Treasury — Internal Revenue or
Service
to renew the CPEO Consent to Disclosure of Tax Information.

A Certified Professional Employer Organization (CPEO) and its customer must complete this form to notify the IRS that a service contract
has started or ended.
The customer or CPEO can complete Parts 1 and 2. The CPEO must complete Parts 3 and 4 before the customer signs Part 5. The CPEO must also
The customer
CPEO
can complete
1 and of
2, Tax
but Information
the customer
mustsending
sign Part
before
theIRS.
CPEO
this form
to the IRS.
complete
Part 6 or
and
the CPEO
Consent toParts
Disclosure
before
this2form
to the
Seesends
the separate
instructions
for The
details on
CPEO
must complete
Part
3, Part
4, and the
CPEO Consent
to Disclosure
of Tax
Information
before
sending
this form of
toTax
the Information.
IRS.
how
to complete
this form
if you're
correcting
a previously
filed Form
8973 or you're
renewing
the CPEO
Consent
to Disclosure

Why are you filing this form? Check only one box.

Part 1:

A service contract started on

/

/

between the customer reported in Part 2 and the CPEO reported in Part 3.

A service contract ended on

/

/

between the customer reported in Part 2 and the CPEO reported in Part 3.

[] Correcting a previously filed Form 8973.

Customer Information

Part 2:
1

Customer’s employer identification number (EIN)

2

Customer’s name (not your trade name)

3
4

—

INTERNAL USE ONLY
DRAFT AS OF
July 28, 2016
Customer’s trade name (if any)
Address

Number

Street

Suite or room number

City

State

Foreign country name

5

Foreign province/county

ZIP code

Foreign postal code

All employees of
customer reported
by CPEO

Forms that the CPEO will file or stop filing. Check all that apply.

Some employees of
customer reported
by CPEO

Form 940, 940-PR (Employer’s Annual Federal Unemployment (FUTA) Tax Return)
Form 941, 941-PR, 941-SS (Employer’s QUARTERLY Federal Tax Return)
Form 943, 943-PR (Employer’s Annual Federal Tax Return for Agricultural
Employees)

"Move after Part 4 and title
this section 'Part 5:
Form 944, 944(SP), Employer’s ANNUAL Federal Tax Return
Customer Signature."
Form CT-1 (Employer’s Annual Railroad Retirement Tax Return)

Part 5: Customer Signature
IUnder
am authorizing
to disclose
otherwise
confidential
tax this
information
to any
the CPEO
related to
thetoauthority
under this form,
including
penaltiesthe
of IRS
perjury,
I declare
that I have
examined
form and
attachments,
and
the bestgranted
of my knowledge
and belief,
it is true, correct,
disclosures
required
to process
Formthe
8973.
I certify
I havethis
theform
authority
to execute
this
form forinthe
customer
reported in Part 2.
and complete.
I certify
that I have
authority
tothat
execute
for the
customer
reported
Part
2.

✗

Sign your
name here

Date

Print your
name here

/

/

Email Address

Print your
title here
Best daytime phone
Now give this form to the CPEO to complete ■▶

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

IRS.gov/form8973

Cat. No. 37796R

Form 8973 (12-2016)

2-2017

D

"Move to page 1."
Part 3:

Version A, Cycle 8

CPEO Information

6

CPEO’s employer identification number (EIN)

7

CPEO’s name (not your trade name)

8

CPEO’s trade name (if any)

9

Address
Number

—

Street

Suite or room number

City

Part 4:
10
11

State

ZIP code

Customer Relationship Information
Is the customer reported in Part 2 a provider of employment-related services (for example,
a professional employer organization)? . . . . . . . . . . . . . . . . .

Yes

No

INTERNAL USE ONLY
DRAFT AS OF
July 28, 2016

11
10

Is your relationship with the customer reported in Part 2 subject to a contract described
under section 7705(e)(2)? . . . . . . . . . . . . . . . . . . . . . .

Yes

No

*

*If "No," skip lines 1113.

12

Is the customer reported in Part 2 a related party? See the separate instructions

13

Do you apply the exemptions, exclusions, definitions, and other rules which are based on
type of employer under sections 3511(a)(2) and 3511(c)(2) to the customer reported in
Part 2? . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.

.

.

.

Yes

No

Yes

No

Part 6: CPEO Signature
Under penalties of perjury, I declare that I have examined this form and any attachments, and to the best of my knowledge and belief, it is true, correct,
and complete. I certify that I have the authority to execute this form for the CPEO reported in Part 3.

✗

Sign your
name here

Date
Email Address
Page 2

Print your
name here

/

/

Print your
title here
Best daytime phone
Form 8973 (12-2016)
2-2017

Version A, Cycle 9

2-2017
Form 8973 (12-2016)

CPEO Consent to Disclosure of Tax Information
To maintain certification, a Certified Professional Employer Organization (CPEO) must complete this
consent to disclose tax information to the customer reported on Form 8973 and send it to the IRS.
By signing, dating, and entering my employer identification number (EIN) at the bottom of this
page, I hereby consent to the IRS disclosing information, as it relates to the customer named below,
from my employment tax returns (for example, Forms 940 and 941). This consent also covers the
disclosure of any information regarding my obligations to report, deposit, and pay federal
employment taxes for the customer named below. I also consent to the disclosure of information
regarding my certification.
The customer named below is authorized to inspect and/or receive the confidential tax information
discussed above for the tax forms and tax periods listed below. See the instructions for details on
how to report the tax periods.
—

Customer’s name (from Form 8973, Part 2)

Customer’s EIN (from Form 8973, Part 2)

INTERNAL USE ONLY
DRAFT AS OF
July 29, 2016
Tax Form Number
(940, 941, 943, 944, CT-1)

Year(s) or Period(s)

I understand that the information to be disclosed is generally confidential under the laws applicable to the IRS and that the customer receiving the
information is not bound by these laws and may use the information for any purpose as permitted by other federal laws and/or state laws. I certify that I
have the authority to execute this consent for the employment tax returns and tax periods shown above.

✗

Sign your
name here

Date

CPEO’s EIN
Page 3

Print your
name here

/

Print your
title here

/
—

CPEO's name [

]

Form 8973 (12-2016)

2-2017