Form 8973 Certified Professional Employer Organization/Customer Re

8973

Form

(May 2017)

Certified Professional Employer Organization/Customer
Reporting Agreement

OMB No. 1545-2266

Department of the Treasury — Internal Revenue Service

Read the separate instructions before you complete Form 8973.

Part 1:

Why are you filing this form?

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.

Part 2:

Customer Information

1

Customer’s employer identification number (EIN)

2

Customer’s name (not your trade name)

3

Customer’s trade name (if any)

4

Address
Number

—

Street

Suite or room number

City

State

Foreign country name

Foreign postal code

Foreign province/county

Identify forms that the CPEO will file reporting wages or compensation paid to
employees performing services for the customer. Check all that apply.

5

ZIP code

CPEO reports all wages/
compensation paid to
employees

CPEO reports some
wages/compensation
paid to employees

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)
Form CT-1 (Employer’s Annual Railroad Retirement Tax Return)

Part 3:

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

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

State

www.irs.gov/Form8973

ZIP code

Cat. No. 37796R

Form 8973 (5-2017)

Part 4:
10

Customer Relationship Information
Is the CPEO's relationship with the customer reported in Part 2 subject to a contract
described under section 7705(e)(2) (also called a CPEO contract)? . . . . . . . .

Yes
No*
*If “No,” skip lines 11-13.

11

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

Yes

No

12

Is the customer reported in Part 2 a related party of the CPEO?

Yes

No

13

Does the CPEO 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

Part 5:

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.

.

.

.

.

.

.

.

Customer Signature

I declare that I have examined this form, and to the best of my knowledge and belief, Parts 1, 2, and 4 are true, correct, and complete. I certify that
I have the authority to execute this form for the customer reported in Part 2.

✗

Sign your
name here

Date

Print your
name here

/

/

Email address

Part 6:

Print your
title here
Best daytime phone

CPEO Signature

Under penalties of perjury, I declare that I have examined this form, 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 (5-2017)

Form 8973 (5-2017)

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 extent necessary to carry out the purposes of the CPEO program, to
the IRS disclosing, to the customer named below, information from my employment tax returns (for
example, Forms 940 and 941) filed with respect to the customer named below. 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
about my certification, regardless of year.
The customer named below is authorized to inspect and/or receive the confidential tax information
identified 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)

Tax Form Number
(940, 941, 943, CT-1)

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

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.

✗

Sign your
name here

Date

CPEO’s EIN

Print your
name here

/

Print your
title here

/
—

CPEO’s name
Page 3

Form 8973 (5-2017)