IRS Form 4219 "Statement of Liability of Lender, Surety, or Other Person for Withholding Taxes"

IRS Form 4219 is a U.S. Department of the Treasury - Internal Revenue Service form also known as the "Irs Form 4219 "statement Of Liability Of Lender, Surety, Or Other Person For Withholding Taxes"". The latest edition of the form was released in May 1, 2014 and is available for digital filing.

Download a PDF version of the IRS Form 4219 down below or find it on U.S. Department of the Treasury - Internal Revenue Service Forms website.

ADVERTISEMENT

Download IRS Form 4219 "Statement of Liability of Lender, Surety, or Other Person for Withholding Taxes"

650 times
Rate
(4.4 / 5) 39 votes
Statement of Liability of Lender, Surety, or
4219
OMB Number
Form
Other Person for Withholding Taxes
1545-2254
(Rev. May 2014)
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
2. Employer identification number
(as used on employment tax return)
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
a. Income tax
Computation of
9. Amount of employees taxes required to be
b. FICA tax
Liability for
withheld by employer
Withholding Taxes
c. Railroad retirement tax
on Wages Paid
10. Total taxes required to be withheld by employer
(Sum of Items 9a, b, and c)
Directly to
Employees of
11. Portion of Item 10 paid by employer
Borrower
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
Computation of
b. FICA tax
withheld by employer
Liability for
c. Railroad retirement tax
Withholding Taxes
on Funds Supplied
15. Total taxes required to be withheld by employer
(Sum of Items 14a, b, and c)
for Specific
16. Portion of Item 15 paid by employer
Purpose of Paying
Wages
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.)
19. Liability where wages paid directly to employees
(Item 12)
20. Liability where funds supplied for payment of wages
(Item 18)
Total
21. Total liability for withholding taxes
(Sum of Items 19 and 20)
Liability
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
4219
Form
(Rev. 5-2014)
Catalog Number 41456S
www.irs.gov
Department of the Treasury—Internal Revenue Service
Statement of Liability of Lender, Surety, or
4219
OMB Number
Form
Other Person for Withholding Taxes
1545-2254
(Rev. May 2014)
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
2. Employer identification number
(as used on employment tax return)
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
a. Income tax
Computation of
9. Amount of employees taxes required to be
b. FICA tax
Liability for
withheld by employer
Withholding Taxes
c. Railroad retirement tax
on Wages Paid
10. Total taxes required to be withheld by employer
(Sum of Items 9a, b, and c)
Directly to
Employees of
11. Portion of Item 10 paid by employer
Borrower
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
Computation of
b. FICA tax
withheld by employer
Liability for
c. Railroad retirement tax
Withholding Taxes
on Funds Supplied
15. Total taxes required to be withheld by employer
(Sum of Items 14a, b, and c)
for Specific
16. Portion of Item 15 paid by employer
Purpose of Paying
Wages
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.)
19. Liability where wages paid directly to employees
(Item 12)
20. Liability where funds supplied for payment of wages
(Item 18)
Total
21. Total liability for withholding taxes
(Sum of Items 19 and 20)
Liability
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
4219
Form
(Rev. 5-2014)
Catalog Number 41456S
www.irs.gov
Department of the Treasury—Internal Revenue Service
2
4219
Form
(Rev. 5-2014)
Page
General Instructions
Who must file Form 4219—File this form if you are a lender, surety, or
For purposes of section 3505(b), an organization is deemed to have
other person who, by reason of having paid wages directly to employees
actual notice or knowledge of any fact relating to a transaction from the
of another employer, or having supplied funds for the purpose of paying
time that fact is brought to the attention of the individual conducting the
wages to employees of another employer, has incurred liability under
transaction, and in any event from the time that fact would have been
section 3505 of the Internal Revenue Code for taxes required to be
brought to the individual's attention if the organization had exercised due
withheld. If you are an employer within the meaning of code section 3401
diligence, as defined in Code section 6323(i)(1).
(d)(1) or (d)(2) and the related regulations, do not use Form 4219 to
The liability under section 3505 does not extend to the portion of the
report income tax withholding.
employer's taxes imposed under the Federal Insurance Contributions Act
Internal Revenue Code—Section 3505(a) provides that if a lender,
or the Railroad Retirement Tax Act. Under Section 3505, the employer
surety, or other person pays wages directly to employees of another
remains liable for withholding taxes not paid by the lender, surety, or
employer, or to an agent of such employees, the lender, surety, or other
other person, and is required to file an employment tax return for such
person is liable for payment to the United States of a sum equal to the
wages paid by the employer, a lender, surety, or other person, and
following taxes (and interest) required to be withheld from such wages by
furnish statements to employees of taxes withheld.
the other employer:
Separate Form 4219 for each employer and each calendar quarter—
(a) FICA tax required to be withheld under section 3102;
A separate Form 4219 should be submitted, in duplicate, for each
employer and for each calendar quarter for which liability under section
(b) Railroad retirement tax required to be withheld under section
3505 is incurred.
3202; and
Where to file—File Form 4219 with the office of the Internal Revenue
(c) Income tax required to be withheld under section 3402.
Service where the employer for whom wages were paid or funds were
Section 3505(b) provides that if a lender, surety, or other person supplies
supplied files Federal employment tax returns.
funds to or for the account of another employer for the specific purpose
Payment—Include with each Form 4219 a remittance (check or money
of paying wages of the employees of the other employer, with actual
order) for the amount shown in item 23, payable to the United States
notice or knowledge that the employer does not intend, or will not be
Treasury. Payment of the withholding taxes shown on Form 4219 by
able, to make timely payment or deposit of the above taxes required to
either the employer or the lender, surety, or other person satisfies the
be withheld by the employer, the lender, surety, or other person is liable
liability. If neither the employer nor the lender, surety, or other person
for payment to the United States of a sum equal to the taxes, plus any
pays these taxes, the U.S. Government may collect the unpaid amount
interest, that are not paid by the employer. However, the liability under
by appropriate civil action. To avoid the accumulation of interest, make
section 3505(b) cannot exceed 25% of the amount supplied specifically
the payment on or before the due date of the employer's (borrower's)
for the purpose of paying of wages. Section 3505(b) does not apply to
Federal employment tax return.
ordinary working capital loans to employers, even though it is known that
part of the funds advanced will be used to pay wages.
Specific Instructions
Item 4. Enter the last day of the calendar quarter during which the wages
Item 14. Enter in items 14a, b, and c the amounts of employee taxes
were actually paid to the employees of another employer. If funds were
required to be withheld by the employer from wages paid during this
supplied to the employer for payment of wages, show the last day of the
quarter with funds supplied for that specific purpose.
calendar quarter during which the wages were actually paid by the
Item 22. If the liability is paid after the due dates of the employer's
employer.
Federal employment tax return, interest will be charged at the annual
Item 9. Enter in items 9a, b, and c the amounts of employee taxes
rate established under Internal Revenue Code section 6621(a) subject to
required to be withheld as if the wages were paid by the employer.
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
example, we may disclose your tax information to the Department of Justice for civil
of the United States. We need it to figure and collect the right amount of tax.
and criminal litigation, and to cities, states, the District of Columbia, and U.S.
Subtitle C, Employment Taxes, of the Internal Revenue Code imposes employment
commonwealths and possessions for use in administering their tax laws. We may
taxes on wages, including income tax withholding. Form 4219 is used to determine
also disclose this information to other countries under a tax treaty, to federal and
if you as a lender, surety or other person who paid wages directly to employees of
state agencies to enforce federal nontax criminal laws, or to federal law
another employer, has incurred liability under section 3505 for taxes required to be
enforcement and intelligence agencies to combat terrorism.
withheld. Section 6011 requires you to provide the requested information if the tax
The time needed to complete and file Form 4219 will vary depending on
is applicable to you. Section 6109 requires you to provide your identification
individual circumstances. The estimated average time is: Recordkeeping, 11 hr.;
number. If you fail to provide this information in a timely manner, or provide false or
Learning about the law or the form, 50 min.; Preparing, copying, assembling,
fraudulent information, you may be subject to penalties.
and sending the form to the IRS, 1 hr.
You are not required to provide the information requested on a form that is
If you have comments concerning the accuracy of these time estimates or
subject to the Paperwork Reduction Act unless the form displays a valid OMB
suggestions for making Form 4219 simpler, we would be happy to hear from you.
control number. Books and records relating to a form or its instructions must be
You can email us at taxforms@irs.gov. Enter “Form 4219” on the subject line. Or
retained as long as their contents may become material in the administration of any
write to: Internal Revnue Service, Tax Products Coordinating Committee, SE:W:
Internal Revenue law.
CAR:MP:T:M:S, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224. Do
Generally, tax returns and return information are confidential, as required by
not send Form 4219 to this address. Instead, see Where to File? in the instructions
section 6103. However, section 6103 allows or requires the IRS to disclose or give
for Form 4219.
the information shown on your tax return to others as described in the Code. For
4219
Form
(Rev. 5-2014)
Catalog Number 41456S
www.irs.gov
Department of the Treasury—Internal Revenue Service
ADVERTISEMENT
Page of 2