This form contains 40 fields organized into 9 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Firm Information
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row1[0].f1_3[0 Text
Enter the name of the firm you worked for where you believe you were misclassified as an independent contractor.
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row1[0].f1_4[0 Text
Enter the Employer Identification Number (EIN) of the firm you worked for. This should be an 11-digit number.
Max length: 11 characters
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row2[0].f1_8[0 Text
Enter the name of another firm you worked for where you believe you were misclassified as an independent contractor, if applicable.
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row2[0].f1_9[0 Text
Enter the Employer Identification Number (EIN) of the second firm you worked for, if applicable. This should be an 11-digit number.
Max length: 11 characters
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row3[0].f1_17[0 Text
Enter the name of the firm you worked for.
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row4[0].f1_18[0 Text
Enter the address of the firm you worked for.
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row4[0].f1_19[0 Text
Enter the Employer Identification Number (EIN) of the firm. This should be a 9-digit number.
Max length: 11 characters
General Information
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row5[0].f1_25[0 Text
This field is likely a checkbox or a small text field. Please refer to the form instructions to determine the specific value required.
Max length: 1 characters
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row5[0].f1_26[0 Text
Enter the specific information requested in this field. The maximum length is 10 characters.
Max length: 10 characters
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row5[0].c1_5[0 CheckBox
Check this box if the condition specified in the form applies to you.
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row5[0].f1_27[0 Text
Enter the specific information requested in this field.
topmostSubform[0].Page1[0].f1_28[0 Text
Enter the specific information requested in this field.
topmostSubform[0].Page1[0].f1_29[0 Text
Enter the specific information requested in this field.
8 Text
Enter the specific information requested in this field.
9 Text
Enter the specific information requested in this field.
10 Text
Enter the specific information requested in this field.
topmostSubform[0].Page1[0].f1_33[0 Text
Enter the specific information requested in this field.
topmostSubform[0].Page1[0].f1_34[0 Text
Enter the specific information requested in this field.
Personal Information
topmostSubform[0].Page1[0].f1_1[0 Text
Enter your full name as it appears on your Social Security card.
Social security number Text
Enter your Social Security number. This should be a 9-digit number.
Max length: 11 characters
Reason for Filing
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row4[0].f1_20[0 Text
Enter the reason code for filing Form 8919. This should be a single character code.
Max length: 1 characters
Supporting Documentation
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row1[0].c1_1[0 CheckBox
Check this box if you have attached a statement explaining why you believe you were misclassified as an independent contractor.
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row4[0].c1_4[0 CheckBox
Check this box if you have attached a statement explaining why you believe you were misclassified as an independent contractor.
Tax Calculation
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row1[0].f1_7[0 Text
Enter the amount of Social Security tax that should have been withheld from your wages.
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row4[0].f1_22[0 Text
Enter the Social Security tax amount that should have been withheld.
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row5[0].f1_23[0 Text
Enter the Medicare tax amount that should have been withheld.
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row5[0].f1_24[0 Text
Enter the total amount of uncollected Social Security and Medicare taxes.
Max length: 11 characters
Add lines 11 and 12. Enter here. Include as tax on your annual tax return (Schedule 2 (Form 1040), line 6; 13 13 Text
Add the amounts from lines 11 and 12 and enter the total here. This amount should be included as tax on your annual tax return (Schedule 2 (Form 1040), line 6).
Tax Calculations
9 Subtract line 8 from line 7. If line 8 is more than line 7, enter -0- here and on line 10 Text
Enter the result of subtracting the value in line 8 from the value in line 7. If the value in line 8 is greater than the value in line 7, enter 0 here and on line 10.
Max length: 1 characters
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row2[0].f1_11[0 Text
Enter the appropriate value as indicated in the form instructions. This field is part of the tax calculation section.
Max length: 10 characters
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row2[0].c1_2[0 CheckBox
Check this box if the condition specified in the form instructions applies to you.
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row2[0].f1_12[0 Text
Enter the appropriate value as indicated in the form instructions. This field is part of the tax calculation section.
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row3[0].f1_13[0 Text
Enter the appropriate value as indicated in the form instructions. This field is part of the tax calculation section.
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row3[0].f1_14[0 Text
Enter the appropriate value as indicated in the form instructions. This field is part of the tax calculation section.
Max length: 11 characters
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row3[0].f1_15[0 Text
Enter the appropriate value as indicated in the form instructions. This field is part of the tax calculation section.
Max length: 1 characters
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row3[0].f1_16[0 Text
Enter the appropriate value as indicated in the form instructions. This field is part of the tax calculation section.
Max length: 10 characters
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row3[0].c1_3[0 CheckBox
Check this box if the condition specified in the form instructions applies to you.
Tax Information
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row1[0].f1_5[0 Text
Enter the tax year for which you are filing this form. This should be a 4-digit year.
Max length: 1 characters
Wage Information
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row1[0].f1_6[0 Text
Enter the total amount of wages you received from the firm during the tax year.
Max length: 10 characters
topmostSubform[0].Page1[0].Table_Lines1-5[0].Row4[0].f1_21[0 Text
Enter the total amount of wages paid to you by the firm.
Max length: 10 characters