Form 4219 - Statement of Liability of Lender, Surety, or Other Person for Withholding Taxes (2014)

Form 4219 (Rev. 5-2014)
Catalog Number 41456S www.irs.gov Department of the Treasury—Internal Revenue Service
Form 4219
(Rev. May 2014)
Statement of Liability of Lender, Surety, or
Other Person for Withholding Taxes
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
Computation of
Liability for
Withholding Taxes
on Wages Paid
Directly to
Employees of
Borrower
9. Amount of employees taxes required to be
withheld by employer
a. Income tax
b. FICA tax
c. Railroad retirement tax
10. Total taxes required to be withheld by employer (Sum of Items 9a, b, and c)
11. Portion of Item 10 paid by employer
12. Liability for withholding taxes (Item 10 minus Item 11. Enter here and in Item 19.)
Computation of
Liability for
Withholding Taxes
on Funds Supplied
for Specific
Purpose of Paying
Wages
13. Amount supplied to employer for paying wages
$
14. Amount of employee taxes required to be
withheld by employer
a. Income tax
b. FICA tax
c. Railroad retirement tax
15. Total taxes required to be withheld by employer (Sum of Items 14a, b, and c)
16. Portion of Item 15 paid by employer
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.)
Total
Liability
19. Liability where wages paid directly to employees (Item 12)
20. Liability where funds supplied for payment of wages (Item 18)
21. Total liability for withholding taxes (Sum of Items 19 and 20)
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
OMB Number
1545-2254
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Form 4219 - Statement of Liability of Lender, Surety, or Other Person for Withholding Taxes (2014) PDF

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