Form Form-8945 PTIN Supplemental Application For U.S. Citizens Without

OK-TO-PRINT AS CORRECTED JB 08/18/10

Version A, Cycle 2

Approved for the TPCC Chairperson AS CORRECTED, Johnny Cervantes, 8/23/2010

8945

Lower case a

PTIN Supplemental Application For U.S. Citizens
Without A Social Security Number Due To
Conscientious Religious Objection

Form
(September 2010)
Department of the Treasury
Internal Revenue Service

OMB No. 1545-XXXX

Do not submit this form if you have a U.S. Social Security Number (SSN).

Part I

DRAFT AS OF
August 18, 2010

To Be Completed by Preparer
1

Name
Applicant’s
Complete
Mailing Address
Birth
Information

Citizenship
and
Identification
Information

2

First name

Middle name

Last name

Street address, apt. number, or rural route number. If you have a P.O. box, see instructions.
City or town, state, and ZIP code

3

5

Date of birth (mm/dd/yyyy)

Country of birth

Name at birth (if different from above)
First name

Middle name

4

Last name

Citizenship and identification document(s) submitted (see instructions)
Passport/Passport Card
U.S. Driver’s License
Voter's Registration Card
Civil Birth Certificate

Male
Female

U.S. State ID Card

U.S. Military ID Card
Naturalization Papers

Foreign Military ID Card

I certify that I am and continuously have been a member of
(Name of religious group)
since
(Religious district or congregation, and county and/or city, state, and ZIP code)

(Month)

(Day)

(Year)

and as a follower of the established teachings of the group, I am conscientiously opposed to applying for and receiving a social security number.
Furthermore, I state that an application for a social security number was never filed by me or on my behalf, and that I have never received a social
security number. Under penalty of perjury, I declare that I have examined this application, including accompanying documentation and statements, and
to the best of my knowledge and belief, it is true, correct, and complete.

penalties

Signature of Applicant ▶

Part II

Date ▶

To Be Completed by Authorized Representative of Religious Group

I certify that

is a member of

(Name of religious group/district/congregation)
(Name of preparer)
and as a dutiful follower of aforementioned religious group, has a religious objection to applying for and receiving a social security number.
Name of Authorized Representative (print or type)

Signature of Authorized
Representative ▶

Address

Date ▶

Title ▶

For IRS Use Only

Is it possible/desirable to make the font bigger? There is a lot white space between the end of the text
and the signature area.

For Privacy Act and Paperwork Reduction Act Notice, see instructions.

Cat. No. 37763W

Form 8945 (9-2010)