Statement of Payments Received

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-0364 can be found here:

Documents and Forms

Document Name Document Type
Form 4669 Statement of Payments Received Form and Instruction
4669 Statement of Payments Received Form_4669[1].pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Payments Received	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4669	Statement of Payments Received	Form_4669[1].pdf		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title: IRS 24.046 BMF, and Treas/IRS 34.047 audit trail and security records	FR Citation: 83 FR 42980

Number of Respondents: 85,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	85,000	85,000
Annual IC Time Burden (Hours)	21,250	21,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.