Return Preparer Data Collected through Processing

Return Preparer Office Testing and Fingerprinting Programs
Return Preparer Information to be Collected / Subject to OMB Approval
Information Provided via Form W-12 and entered into TPPS system (has already been approved)		Information passed from TPPS to Prometric	Information passed from TPPS to Prometric / LexisNexis and Daon Trusted Identity	Notes
Name	Last name	Last name	Last name
	First name and initial	First name	First name
		Middle name	Middle name	Middle name will be provided at the time the candidate schedules a test and/or fingerprinting appointment
Mailing Address	Street address	Street address	Street address
	City	City	City
	State	State	State
	Zip code	Zip code	Zip code
		Home phone Number	Home phone number	Home phone number will be provided at the time the candidate schedules a test and/or fingerprinting appointment
SSN and Date of Birth	SSN
	Date of birth (month, day, year)	Date of birth (month, day, year)	Date of birth (month, day, year)
Email Address	Email address	Email address
Address of Your Last Individual Income Tax Return Filed	Street address
	City
	State
	Zip code
Filing Status and Tax Year on Last Individual Income Tax Return Filed	[ ] Single [ ] Head of Household [ ] Married filing jointly [ ] Qualifying widow(er) with dependent child [ ] Married filing separately Tax Year _____________
Federal Tax Compliance	Are you current on both your individual and business federal taxes, including any corporate and employment tax obligations? [ ] Yes [ ] No If "no", provide an explanation._______________________________
Past Felony Convictions	Have you been convicted of a felony in the past 10 years? [ ] Yes [ ] No If "Yes", provide an explanation.______________________________
Business Name and Identification Numbers	Business Name
	EIN
	EFIN
Business Physical Address
	Street Address
	City
	State
	Zip Code
Business Phone Number	Business phone number (domestic)
	Business phone number (international)
Business Web Address	Business website address
CAF Number	Central Authorization File (CAF) number(s)
Professional Credentials	Check all that apply and enter appropriate number(s): [ ] Attorney - Licensed in which states____________numbers______ [ ] Certified Public Accountant-Licensed in which states__number___ [ ] Enrolled Agent______________________________________ [ ] Enrolled Actuary_____________________________________ [ ] Enrolled Retirement Plan Agent__________________________ [ ] Certified Acceptance Agent__________________________________ [ ] State Regulated Tax Preparer-States_____numbers___________ [ ] None
Fee	Make check or money order payable to…..	Pay by credit card or e-check	Pay by credit card or e-check
Signature	Signature under penalties of perjury…
	Date
		IRS Registration File Number (TPPS generated)	IRS Registration File Number (TPPS generated)
			Additional Information to be collected at fingerprinting kiosk:	This information (except for the last item) is required for the FBI background investigation
			Gender
			Race
			Eye color
			Hair color
			Height (feet and inches)
			Weight
			Citizenship (country code for US Citizenship or country of origin)
			Place of birth
			Aliases (all aliases used but not a required field)
			Reason fingerprinted (check all that apply) [ ] PTIN [ ] EFIN [ ] ITIN