Form W-12 Form W-12 - IRS Paid Preparer Tax Identification Number

Application

Form

OMB Number

W-12

IRS Paid Preparer Tax
Identification Number (PTIN) Registration 1545-XXXX

Department of the Treasury
Internal Revenue Service

1 Name

Last name

First name and initial

(Print or Type)

2 Mailing Address

Street address. Use a P.O. box number only if the post office does not deliver mail to your street address.

City or town, state/province, and, if outside U.S., country. Include ZIP or postal code where appropriate. Do
not abbreviate name of country.

3 SSN and Date of
Birth

SSN

4 Email Address

Enter the email address that should be used to contact you

5 Address of Your
Last Individual
Income Tax
Return Filed

Street address. Use a P.O. box number only if the post office does not deliver mail to your street address.

6 Federal Tax
Compliance

Date of birth (month, day, year)

__ __ __ - __ __ - __ __ __ __

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City or town, state/province, and, if outside U.S., country. Include ZIP or postal code where appropriate. Do
not abbreviate name of country.

Are you current on both your individual and business federal taxes?

Yes

No

If no, provide an explanation.

7 Past Felony
Convictions

Have you been convicted of a felony in the past 10 years?

Yes

No

If yes, provide the jurisdiction (state/country) in which you were convicted, and an explanation.

Note. If you are a managing member, corporate officer, or owner of a business that is paid to prepare federal tax returns,
complete lines 8, 9, 10, and 11. Otherwise, skip these lines and continue on to line 12.

EIN

8 Business Name
and
Identification
Numbers
9 Business
Physical
Address

Doing Business As (DBA)

10 Business Phone
Number

Business phone number (domestic)

Business phone number (international)

(

+_ _ _ _ _ _ _ _ _ _ _ _ _

11 Business

EFIN

__ __ - __ __ __ __

__-________
Street address. Do not enter a P.O. box.

City or town, state/province, and, if outside U.S., country. Include ZIP or postal code where appropriate. Do
not abbreviate name of country.

) __ __ __ - __ __ __ __

website

If you are the owner, corporate officer, or managing member, enter your business webstie address

Website Address

12 CAF Number

Enter any central authorization file (CAF) number(s) you may have

13 Professional
Certifications

Check all that apply:

14 Fee

Attorney - Licensed in which state(s): _____________ BAR Number:_________
Certified Public Accountant - Licensed in which state(s): ____________
Enrolled Agent-Registration Number:________________
Enrolled Actuary
Enrolled Retirement Plan Agent
□ Certified Acceptance Agent
□ State Regulated Tax Preparer-State(s)________ License Number(s)__________
None
There is a fee of $50+ to request a PTIN. The fee is nonrefundable. Full payment must be included with
your request or it will be rejected. Make your check or money order payable to IRS Tax Pro PTIN Fee.
Do not use paper clips or staples.
► $50+
Under penalties of perjury, I declare that I have examined this application and to the best of my knowledge
and belief, it is true, correct, and complete. Further, I certify that I will use my preparer tax identification
number only to identify myself on returns or claims for refund that I prepare for compensation.

Sign Here

Your Signature

Date (MM, DD, YYYY)

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