8836 Qualifying Children Residency Statement

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4361

Form
(Rev. November 2005)

Department of the Treasury
Internal Revenue Service

I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 4361, PAGE 1 of 2
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20 INK: BLACK
FLAT SIZE: 203mm (8") x 279mm (11")
PERFORATE: (NONE)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Action

Date

Signature

O.K. to print
Revised proofs
requested

Application for Exemption From Self-Employment Tax
for Use by Ministers, Members of Religious Orders
and Christian Science Practitioners

OMB No. 1545-0074

File Original
and Two Copies

Please type or print

File original and two copies and attach supporting documents. This exemption is granted only if the IRS returns a copy to you marked “approved.”

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4

1 Name of taxpayer applying for exemption (as shown on Form 1040)

Social security number

Number and street (including apt. no.)

Telephone number (optional)

(

)

City or town, state, and ZIP code

3 Date ordained, licensed, etc.
(Attach supporting
Commissioned or licensed minister (see line 6)
Member of religious order not under a vow of poverty
document. See instructions.)
Legal name of ordaining, licensing, or commissioning body or religious order
Check one box:

Christian Science practitioner

Ordained minister, priest, rabbi

/

/

Employer identification number

Number, street, and room or suite no.
City or town, state, and ZIP code
5

Enter the first 2 years, after the date shown on line 3, that you had net self-employment earnings of $400 or
more, any of which came from services as a minister, priest, rabbi, etc.; member of a religious order; or Christian
䊳
Science practitioner

6

If you apply for the exemption as a licensed or commissioned minister, and your denomination also ordains ministers, please indicate how your
ecclesiastical powers differ from those of an ordained minister of your denomination. Attach a copy of your denomination’s bylaws relating to
the powers of ordained, commissioned, and licensed ministers.

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I certify that I am conscientiously opposed to, or because of my religious principles I am opposed to, the acceptance (for services I perform
as a minister, member of a religious order not under a vow of poverty, or a Christian Science practitioner) of any public insurance that
makes payments in the event of death, disability, old age, or retirement; or that makes payments toward the cost of, or provides services
for, medical care. (Public insurance includes insurance systems established by the Social Security Act.)
I certify that as a duly ordained, commissioned, or licensed minister of a church or a member of a religious order not under a vow of poverty,
I have informed the ordaining, commissioning, or licensing body of my church or order that I am conscientiously opposed to, or because of
religious principles, I am opposed to the acceptance (for services I perform as a minister or as a member of a religious order) of any public
insurance that makes payments in the event of death, disability, old age, or retirement; or that makes payments toward the cost of, or
provides services for, medical care, including the benefits of any insurance system established by the Social Security Act.
I certify that I have never filed Form 2031 to revoke a previous exemption from social security coverage on earnings as a minister, member
of a religious order not under a vow of poverty, or a Christian Science practitioner.
I request to be exempted from paying self-employment tax on my earnings from services as a minister, member of a religious order not
under a vow of poverty, or a Christian Science practitioner, under section 1402(e) of the Internal Revenue Code. I understand that the
exemption, if granted, will apply only to these earnings. Under penalties of perjury, I declare that I have examined this application and to
the best of my knowledge and belief, it is true and correct.

Signature

䊳

Date

䊳

Caution: Form 4361 is not proof of the right to an exemption from Federal income tax withholding or social security tax, the right to a parsonage
allowance exclusion (section 107 of the Internal Revenue Code), assignment by your religious superiors to a particular job, or the exemption or
church status of the ordaining, licensing, or commissioning body, or religious order.

For Internal Revenue Service Use
Approved for exemption from self-employment tax on ministerial earnings
Disapproved for exemption from self-employment tax on ministerial earnings

By
(Director’s signature)

General Instructions
Section references are to the Internal
Revenue Code.
Purpose of form. File Form 4361 to apply for
an exemption from self-employment tax if you
are:
● An ordained, commissioned, or licensed
minister of a church;
● A member of a religious order who has not
taken a vow of poverty;
● A Christian Science practitioner; or

(Date)

● A commissioned or licensed minister of a
church or church denomination that ordains
ministers, if you have authority to perform
substantially all religious duties of your church
or denomination.
This application must be based on your
religious or conscientious opposition to the
acceptance (for services performed as a
minister, member of a religious order not
under a vow of poverty, or Christian Science
practitioner) of any public insurance that
makes payments for death, disability, old age,
or retirement; or that makes payments for the

For Privacy Act and Paperwork Reduction Act Notice, see page 2

cost of, or provides services for, medical
care, including any insurance benefits
established by the Social Security Act.
If you are a duly ordained, commissioned,
or licensed minister of a church or a member
of a religious order not under a vow of
poverty, prior to filing this form you must
inform the ordaining, commissioning, or
licensing body of your church or order that
you are opposed to the acceptance of public
insurance benefits based on ministerial
service on religious or conscientious grounds.

Cat. No. 41586H

Form

4361

(Rev. 11-2005)

2
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 4361, PAGE 2 of 2
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20 INK: BLACK
FLAT SIZE: 203mm (8") x 279mm (11")
PERFORATE: (NONE)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 4361 (Rev. 11-2005)

Do not file Form 4361 if:
● You ever filed Form 2031, Revocation of
Exemption From Self-Employment Tax for
Use by Ministers, Members of Religious
Orders, and Christian Science Practitioners;
or
● You belong to a religious order and took a
vow of poverty. You are automatically exempt
from self-employment tax on earnings for
services you perform for your church or its
agencies. No tax exemption applies to
earnings for services you perform for any
other organization.
Additional information. See Pub. 517, Social
Security and Other Information for Members
of the Clergy and Religious Workers.
When to file. File Form 4361 by the due date,
including extensions, of your tax return for the
2nd tax year in which you had at least $400
of net earnings from self-employment, any of
which came from services performed as a
minister, member of a religious order, or
Christian Science practitioner.
Effective date of exemption. An exemption
from self-employment tax is effective for all
tax years ending after 1967 in which you have
net self-employment earnings of $400 or
more, if you receive any of it from ministerial
services. For example, if you had qualified net
earnings of $400 or more in 2003 and not
again until 2005, a valid Form 4361 filed by
April 15, 2006, would apply to 2003 and all
later years. See Pub. 517 to find out if you
are entitled to a refund of self-employment
tax paid in earlier years.
Where to file. Mail the original and two
copies of this form to: Internal Revenue
Service, Drop Point S-849, Philadelphia,
PA 19255.
Approval of application. Before your
application can be approved, the IRS must
verify that you are aware of the grounds for
exemption and that you want the exemption
on that basis. When your completed Form
4361 is received, the IRS will mail you a
statement that describes the grounds for
receiving an exemption under section 1402(e).
You must certify that you have read the
statement and seek exemption on the
grounds listed on the statement. The
certification must be made by signing a copy
of the statement under penalties of perjury
and mailing it to the IRS not later than 90
days after the date the statement was mailed
to you. If it is not mailed by that time, your
exemption will not be effective until the date
the signed copy is received by the IRS.
If your application is approved, a copy of
Form 4361 will be returned to you marked
“approved.” Keep this copy of Form 4361 for
your permanent records. Once the exemption
is approved, you cannot revoke it.
Exempt earnings. Only earnings from
ministerial services are exempt from
self-employment tax.
Conducting religious worship services or
ministering sacerdotal functions are ministerial
services whether or not performed for a
religious organization.
Ministerial services also include those
performed under the authority of a church or
church denomination. Examples are
controlling, conducting, and maintaining
religious organizations, including religious
boards, societies, and other agencies integral
to these organizations.

Page

If your church assigns or designates you to
perform services for an organization that is
neither a religious organization nor an integral
agency of a religious organization, you are
performing ministerial services even though
they may not involve conducting religious
worship or ministering sacerdotal functions.
Your services are ordinarily not considered
assigned or designated by your church if any
of the following is true.
● The organization for which you perform the
services did not arrange with your church for
your services.
● You perform the same services for the
organization as other employees not
designated as you were.
● You perform the same services before and
after the designation.
Nonexempt earnings. Exemption from
self-employment tax does not apply to
earnings from services that are not ministerial.
Earnings from the following entities are not
exempt even if religious services are
conducted or sacerdotal functions are
ministered: the United States; a state,
territory, or possession of the United States;
the District of Columbia; a foreign
government; or a subdivision of any of these
bodies. For example, chaplains in the U.S.
Armed Forces are considered commissioned
officers, not ministers. Similarly, chaplains in
state prisons or universities are considered
civil servants.
Indicating exemption on Form 1040. If the
IRS returns your application marked
“approved” and your only self-employment
income was from ministerial services, write
“Exempt—Form 4361” on the
self-employment tax line in the Other Taxes
section of Form 1040. If you had other
self-employment income, see Schedule SE
(Form 1040).

Specific Instructions
Line 3. Enter the date you were ordained,
commissioned, or licensed as a minister of a
church; became a member of a religious
order; or began practice as a Christian
Science practitioner. Do not file Form 4361
before this date. Attach a copy of the
certificate (or, if you did not receive one, a
letter from the governing body of your church)
that establishes your status as an ordained,
commissioned, or licensed minister; a
member of a religious order; or a Christian
Science practitioner.
Line 4. If you are a minister or belong to a
religious order, enter the legal name, address,
and employer identification number of the
denomination that ordained, commissioned,
or licensed you, or the order to which you
belong. Get the employer identification
number from your church or order.
You must be able to show that the body
that ordained, commissioned, or licensed you,
or your religious order, is exempt from
Federal income tax under section 501(a) as a
religious organization described in section
501(c)(3). You must also be able to show that
the body is a church (or convention or
association of churches) described in section
170(b)(1)(A)(i). To assist the IRS in processing
your application, you can attach a copy of the
exemption letter issued to the organization by
the IRS. If that is not available, you can
attach a letter signed by an individual

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authorized to act for the organization stating
that the organization meets both of the above
requirements.
Privacy Act and Paperwork Reduction Act
Notice. The Privacy Act of 1974 and the
Paperwork Reduction Act of 1980 require that
when we ask you for information we must
first tell you our legal right to ask for the
information, why we are asking for it, and
how it will be used. We must also tell you
what could happen if we do not receive it and
whether your response is voluntary, required
to obtain a benefit, or mandatory under the
law.
Our authority to ask for information is
Internal Revenue Code sections 6001, 6011,
and 6012(a), which require you to file a return
or statement with us for any tax for which
you are liable. Your response is mandatory
under these sections. Section 6109 requires
that you provide your social security number
on what you file. This is so we know who you
are, and can process your return and other
papers. You must fill in all parts of the tax
form that apply to you. If you fail to provide
all or part of the information requested on
Form 4361, your application may be denied.
You are not required to provide the
information requested on a form that is
subject to the Paperwork Reduction Act
unless the form displays a valid OMB control
number. Books or records relating to a form
or its instructions must be retained as long as
their contents may become material in the
administration of any Internal Revenue law.
Generally, tax returns and return
information are confidential, as stated in
section 6103. However, section 6103 allows
or requires the Internal Revenue Service to
disclose or give the information shown on
your tax return to others as described in the
Code. For example, we may disclose your tax
information to the Department of Justice to
enforce the tax laws, both civil and criminal,
to cities, states, the District of Columbia, and
U.S. commonwealths or possessions. We
may also disclose this information to other
countries under a tax treaty, or to Federal and
state agencies to enforce Federal nontax
criminal laws and to combat terrorism.
Please keep this notice with your records. It
may help you if we ask you for other
information. If you have any questions about
the rules for filing and giving information,
please call or visit any Internal Revenue
Service office.
The average time and expenses required to
complete and file this form will vary
depending on individual circumstances. For
the estimated averages, see the instructions
for your income tax return.
If you have suggestions for making this
form simpler, we would be happy to hear
from you. You can write to the Internal
Revenue Service, Tax Products Coordinating
Committee, SE:W:CAR:MP:T:T:SP, 1111
Constitution Avenue, NW, IR-6406,
Washington, DC 20224. Do not send the
form to this address. Instead, see Where to
file on this page.