Statement of Payments Received

ICR 202305-1545-025

OMB: 1545-0364

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Unchanged
Supporting Statement A
2023-08-16
IC Document Collections
IC ID
Document
Title
Status
129772 Unchanged
ICR Details
1545-0364 202305-1545-025
Received in OIRA 201905-1545-022
TREAS/IRS
Statement of Payments Received
Extension without change of a currently approved collection   No
Regular 08/30/2023
  Requested Previously Approved
36 Months From Approved 08/31/2023
85,000 85,000
21,250 21,250
0 0

Form 4669, Statement of Payments Received, is used by payors in specific situations to request relief from payment of certain required taxes. A payor who fails to withhold certain required taxes from a payee may be entitled to relief, under sections 3402(d), 3102(f)(3), 1463 or Regulations section 1.1474-4. To apply for relief, a payor must show that the payee reported the payments and paid the corresponding tax. To secure relief as described above, a payor must obtain a separate, completed Form 4669 from each payee for each year relief is requested. The data is used to verify that the income tax on the wages was paid in full. The collection of data affects business, individuals, and households.

US Code: 26 USC 3402 Name of Law: Income Tax Collected at Source
   US Code: 26 USC 3102(f)(e) Name of Law: Deduction of Tax from Wages
  
None

Not associated with rulemaking

  88 FR 31305 05/16/2023
88 FR 60012 08/30/2023
No

1
IC Title Form No. Form Name
Statement of Payments Received 4669 Statement of Payments Received

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 85,000 85,000 0 0 0 0
Annual Time Burden (Hours) 21,250 21,250 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$15,366
No
    Yes
    No
Yes
No
No
No
Susan Morris 702 868-5284 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
08/30/2023


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