Statement of Liability of Lender, Surety, or

Form 4219 Other Person for Withholding Taxes

OMB Number
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 (as used on employment tax return) 2. Employer identification number

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
Liability for b. FICA tax
withheld by employer
Withholding Taxes c. Railroad retirement tax
on Wages Paid
Directly to 10. Total taxes required to be withheld by employer (Sum of Items 9a, b, and c)
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
Computation of 14. Amount of employee taxes required to be
b. FICA tax
Liability for withheld by employer
Withholding Taxes c. Railroad retirement tax
on Funds Supplied 15. Total taxes required to be withheld by employer (Sum of Items 14a, b, and c)
for Specific
Purpose of Paying 16. Portion of Item 15 paid by employer
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

Form 4219 (Rev. 5-2014) Catalog Number 41456S www.irs.gov Department of the Treasury—Internal Revenue Service
Form 4219 (Rev. 5-2014) Page 2

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
(b) Railroad retirement tax required to be withheld under section employer and for each calendar quarter for which liability under section
3202; and 3505 is incurred.

(c) Income tax required to be withheld under section 3402. Where to file—File Form 4219 with the office of the Internal Revenue
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
of paying wages of the employees of the other employer, with actual Payment—Include with each Form 4219 a remittance (check or money
notice or knowledge that the employer does not intend, or will not be order) for the amount shown in item 23, payable to the United States
able, to make timely payment or deposit of the above taxes required to Treasury. Payment of the withholding taxes shown on Form 4219 by
be withheld by the employer, the lender, surety, or other person is liable either the employer or the lender, surety, or other person satisfies the
for payment to the United States of a sum equal to the taxes, plus any liability. If neither the employer nor the lender, surety, or other person
interest, that are not paid by the employer. However, the liability under pays these taxes, the U.S. Government may collect the unpaid amount
section 3505(b) cannot exceed 25% of the amount supplied specifically by appropriate civil action. To avoid the accumulation of interest, make
for the purpose of paying of wages. Section 3505(b) does not apply to the payment on or before the due date of the employer's (borrower's)
ordinary working capital loans to employers, even though it is known that Federal employment tax return.
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 [email protected]. 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

Form 4219 (Rev. 5-2014) Catalog Number 41456S www.irs.gov Department of the Treasury—Internal Revenue Service