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Form (Rev. June 2010)


Hiring Incentives to Restore Employment (HIRE) Act Employee Affidavit

OMB No. 1545-2173

Department of the Treasury Internal Revenue Service

Do not sendthis form to the IRS. Keep this form for your records.

To be completed by new employee. Affidavit is not valid unless employee signs it.
I certify that I have been unemployed or have not worked foranyone for more than 40 hours during the 60-day period ending on the date I began employment with this employer. Your name First date of employment / / Name of employer Social security number ▶Under penalties of perjury, I declare that I have examined this affidavit and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee's signature ▶ Date


/Instructions to the Employer
Section references are to the Internal Revenue Code.

Purpose of Form
Use Form W-11 to confirm that an employee is a qualified employee under the HIRE Act. You can useanother similar statement if it contains the information above and the employee signs it under penalties of perjury. Only employees who meet all the requirements of a qualified employee may complete thisaffidavit or similar statement. You cannot claim the HIRE Act benefits, including the payroll tax exemption or the new hire retention credit, unless the employee completes and signs this affidavit orsimilar statement under penalties of perjury and is otherwise a qualified employee. A “qualified employee” is an employee who: • begins employment with you after February 3, 2010, and before January1, 2011; • certifies by signed affidavit, or similar statement under penalties of perjury, that he or she has not been employed for more than 40 hours during the 60-day period ending on the date theemployee begins employment with you; • is not employed by you to replace another employee unless the other employee separated from employment voluntarily or for cause (including downsizing); and

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