! Employee Additional Medicare Tax actually

CAUTION withheld from employees. If you request their

consent to file a claim for employee RRTA taxes you must tell your employees that you can’t claim a refund of any Tier 1 Employee Additional Medicare Tax on their behalf. See Rev. Proc. 2017-28 for sample language to use in your request.

5a. Check the box on line 5a if your overreported tax includes overcollected Employee RRTA taxes for each affected employee. You’re certifying that you repaid or reimbursed the employees their shares of the prior year Employee RRTA taxes and you received written statements from those employees stating that they didn’t and won’t receive a refund or credit for the prior year taxes. Don’t send these statements to the IRS. Keep them for your records. Generally, all employment tax records must be kept for at least 4 years. Records related to qualified sick leave compensation and qualified family leave compensation for leave taken after March 31, 2021, and before October 1, 2021, should be kept for at least 6 years. Copies must be submitted to the IRS if requested.

5b. Check the box on line 5b if your overreported tax includes overcollected prior year Employee RRTA taxes for each affected employee and you haven’t yet repaid or reimbursed the Employee RRTA taxes. You’re certifying that you received consent from each affected employee to file a claim on the employee share of those taxes and you received written statements from those employees stating that they didn’t and won’t receive a refund or credit for the prior year taxes.

Instructions for Form CT-1 X (Rev. 4-2025) 7

An employee consent must:

• Contain the name, address, and social security number (or truncated taxpayer identification number, when appropriate) of the employee;

• Contain the name, address, and EIN of the employer;

• Contain the tax period(s), the type of tax, and the amount of tax for which the consent is provided;

• Affirmatively state that the employee authorizes the employer to claim a refund for the overpayment of the employee share of tax;

• Include the employee's written statement certifying that the employee hasn't made any previous claims (or the claims were rejected) and won't make any future claims for refund or credit of the amount of the overcollection;

instructions for each line carefully before entering amounts in the columns.

If any line doesn’t apply to you, leave it blank.

If you previously adjusted or amended Form CT-1