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Employment Tax Declaration for an IRS e-file Return
Form 8453-EMP For the period beginning , 20 , and ending , 20 .
(Rev. February 2017) For use with Forms 940, 940-PR, 941, 941-PR, 941-SS, 943, 943-PR, 944, and 945. OMB No. 1545-0967
Department of the Treasury ▶ File electronically. Don't file paper copies.
Internal Revenue Service ▶ Information about Form 8453-EMP and its instructions is at www.irs.gov/form8453emp.
Name (as shown on Form 940, 940-PR, 941, 941-PR, 941-SS, 943, 943-PR, 944, or 945) Employer identification number
Part I Type of Return and Return Information (Whole dollars only)
Check the box for the return that you'll file using this Form 8453-EMP. Enter the amounts from the applicable lines of the return. If any of the
applicable lines on the return are blank, leave line 1b, 1c, 2b, 2c, 3b, 3c, 4b, 4c, 5b, or 5c, whichever is applicable, blank (don't enter -0-).
However, if you entered -0- on the return, enter -0- on the applicable line. Complete a separate Form 8453-EMP for each return.
1a Form 940 check here ▶ b. Total payments to all employees (Form 940, Part 2, line 3) 1b
(all 940 series) c. Balance due (Form 940, Part 4, line 14) . . . . . . . 1c
2a Form 941 check here ▶ b. Total taxes after adjustments and credits (Form 941, Part
(all 941 series) 1, line 12) . . . . . . . . . . . . . . . . . 2b
c. Balance due (Form 941, Part 1, line 14) . . . . . . . 2c
3a Form 943 check here ▶ b. Total wages subject to social security tax (Form 943,
(all 943 series) line 2) . . . . . . . . . . . . . . . . . . 3b
c. Balance due (Form 943, line 15) . . . . . . . . . 3c
4a Form 944 check here ▶ b. Wages, tips, and other compensation (Form 944, Part 1,
line 1) . . . . . . . . . . . . . . . . . . 4b
c. Balance due (Form 944, Part 1, line 11) . . . . . . . 4c
5a Form 945 check here ▶ b. Total taxes (Form 945, line 3) . . . . . . . . . . 5b
c. Balance due (Form 945, line 5) . . . . . . . . . . 5c
Part II Declaration of Taxpayer (see instructions)
6a I'm requesting a refund on Form 940, 940-PR, 941, 941-PR, 941-SS, 943, 943-PR, 944, or 945.
b I authorize the U.S. Treasury and its designated Financial Agent to initiate an electronic funds withdrawal (direct debit) entry
to the financial institution account indicated in the tax preparation software for payment of the federal taxes owed for the
return indicated on lines 1a, 2a, 3a, 4a, or 5a, and the financial institution to debit the entry to this account. To revoke a
payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537 no later than 2 business days prior to the
payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of
taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment.
Under penalties of perjury, I declare that I have an approved role (as identified in the instructions for the employment tax return) within the company listed above and the
information I've given the electronic return originator (ERO), transmitter, and/or intermediate service provider (ISP) and the amounts in Part I above agree with the amounts
on the corresponding return. To the best of my knowledge and belief, the return is true, correct, and complete. I consent to the ERO, transmitter, and/or ISP sending the
return, this declaration, and accompanying schedules and statements to the IRS. I also consent to the IRS sending the ERO, transmitter, and/or ISP an acknowledgment of
receipt of transmission and an indication of whether or not the return is accepted and, if rejected, the reason(s) for the rejection. If the processing of the return or refund is
delayed, I authorize the IRS to disclose to the ERO, transmitter, and/or ISP the reason(s) for the delay, or when the refund was sent.
▲ ▲ ▲
Sign
Here Taxpayer’s signature Print your name and title Date
Part III Declaration of Electronic Return Originator (ERO) and Paid Preparer (see instructions)
I declare that I've reviewed the return indicated above and that the entries on Form 8453-EMP are complete and correct to the best of my knowledge. If I'm only a collector,
I'm not responsible for reviewing the return and only declare that this form accurately reflects the data on the return. The taxpayer will have signed this form before I submit
the return. I'll give the taxpayer a copy of all forms and information to be filed with the IRS, and have followed all other requirements in Pub. 3112, IRS e-file Application and
Participation, and Pub. 4163, Modernized e-File (MeF) Information for Authorized IRS e-File Providers for Business Returns. If I'm also the paid preparer, under penalties of
perjury I declare that I've examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and
complete. This paid preparer declaration is based on all information of which I have any knowledge.
▲
Date Check if Check if self- ERO’s SSN or PTIN
ERO’s ERO’s also paid employed
signature ▲ preparer
Use Firm’s name (or yours EIN
Only if self-employed),
address, and ZIP code Phone no.
Under penalties of perjury, I declare that I've examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is
true, correct, and complete. This declaration is based on all information of which I have any knowledge.
Print/Type preparer’s name Preparer’s signature Date Check if self- PTIN
Paid employed
Preparer ▶ Firm ’sEIN ▶
Firm’s name
Firm’s address
Use Only ▶ Phone no.
For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 62873J Form 8453-EMP (Rev. 2-2017)
