Form 4029 Application for Exemption from Social Security and Medic

Form

4029

Application for Exemption From Social Security and
Medicare Taxes and Waiver of Benefits

(Rev. March 2011)
Department of the Treasury
Internal Revenue Service

▶

OMB No. 1545-0064

Before you file this form, see the instructions under Who may apply on page 2.
▶ Do not use prior versions of this form.

File Three Copies

Caution: Approval of Form 4029 exempts you from social security and Medicare taxes only. The exemption does not apply to federal
income tax. Ministers, members of religious orders, and Christian Science practitioners, see Form 4361, Application for Exemption
From Self-Employment Tax for use by Ministers, Members of Religious Orders, and Christian Science Practitioners.

Part I

To Be Completed by Applicant (Print or type)

Print or type

1 Name of taxpayer

2 Social security number

Address (number, street, or P.O. box)

3 Date of birth

City or town, state, and ZIP code

4 Contact phone number

5

Do not send me my Social Security Statement.

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

since

, and as a follower of the established teachings of that group, I am conscientiously opposed to
(Month)

(Day)

(Year)

accepting benefits of any private or public insurance that makes payments in the event of death, disability, old age, or retirement; or makes payments for the
cost of medical care; or provides services for medical care. Public insurance includes any insurance system established by the Social Security Act.
I request that I be exempted from paying social security and Medicare taxes on my earnings from self-employment under Internal Revenue Code section 1401
and from the employer’s share of social security and Medicare taxes under Internal Revenue Code section 3111.
I further request exemption from the employee’s share of social security and Medicare taxes under Internal Revenue Code section 3101, for my services as an
employee whenever I am employed by an employer who has an identical exemption from social security and Medicare taxes.
I waive all rights to any social security payment or benefit under Titles II and XVIII of the Social Security Act. I understand and agree that no benefits
or other payments of any kind under Titles II and XVIII of the Social Security Act will be paid based on my wages and self-employment income to any
other person. I certify that I have never received benefits or payments under the above titles, nor has anyone else received these benefits based on my
earnings.
I agree to notify the Internal Revenue Service within 60 days of any occurrence that results in my no longer being a member of the religious group described
above, or no longer following the established teachings of this group. See Where to file on page 2.
Furthermore, I understand that if the tax exemption for myself or for my employer under sections 1402(g)(1) or 3127 of the Internal Revenue Code is no longer
effective, this waiver will also no longer be effective for:
• Myself, with respect to all my wages and self-employment income; and
• My employees with respect to wages I may pay to them; and that if my employer’s exemption is no longer in effect, my exemption will end with respect to
wages paid to me by my employer. However, the waiver will no longer be effective only to the extent that benefits and other payments under Titles II and XVIII of
the Social Security Act can be payable on the basis of:
• My self-employment income for and after the first tax year in which the exemption ends; and
• My wages for and after the calendar quarter following the calendar quarter in which the exemption no longer meets the requirements of section 1402(g)(1) or
3127 on which the end of the exemption is based.
Under penalties of perjury, I declare that I have examined this application and waiver, and to the best of my knowledge and belief, it is true and correct.

Signature of Applicant ▶

Part II

Date ▶

To Be Completed by Authorized Representative of Religious Group (Print or type)

I certify that

is a member of

.

(Name of taxpayer)

(Name of religious group/district/congregation)

Name of Authorized Representative
Signature of
Authorized Representative ▶

(Please print or type)

(Address)

Title ▶

Date ▶

Social Security Administration Use Only

This religious group is recognized as being in existence continuously since December 31, 1950, as providing a reasonable level of living for
its dependent members, and as being conscientiously opposed to public or private insurance.
This religious group is not recognized as being in existence continuously since December 31, 1950, as providing a reasonable level of living
for its dependent members, and/or as being conscientiously opposed to public or private insurance.
Signature of
Authorized SSA Representative ▶

Date ▶

Internal Revenue Service Use Only
Approved for exemption from social security and Medicare taxes. (See Caution in Part I above.)
Disapproved for exemption from social security and Medicare taxes.
Signature and Title of
Authorized IRS Representative ▶

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

Date ▶
Cat. No. 41277T

Form 4029 (Rev. 03-2011)

Page 2

Form 4029 (Rev. 03-2011)

General Instructions
Section references are to the Internal Revenue Code.
Purpose of form. Form 4029 is used by members of recognized religious
groups to apply for exemption from social security and Medicare taxes. The
exemption is for individuals and partnerships (when all the partners have
approved certification).
Note. The election to waive social security benefits, including Medicare
benefits, applies to all wages and self-employment income earned before
and during the effective period of this exemption and is irrevocable for that
period.
Who may apply. You may apply for this exemption if you are a member of,
and follow the teachings of, a recognized religious group (as defined below).
If you already have approval for exemption from self-employment taxes, you
are considered to have met the requirements for exemption from social
security and Medicare taxes on wages and do not need to file this form.
You are not eligible for this exemption if you received social security
benefits or payments, or if anyone else received these benefits or payments
based on your wages or self-employment income. However, you can file
Form 4029 and be considered for approval if you paid back any benefits you
received.
Recognized religious group. A recognized religious group must meet all the
following requirements:
• It is conscientiously opposed to accepting benefits of any private or public
insurance that makes payments in the event of death, disability, old age, or
retirement; makes payments for the cost of medical care; or provides
services for medical care (including social security and Medicare benefits).
• It has provided a reasonable level of living for its dependent members.
• It has existed continuously since December 31, 1950.
Certification. In order to complete the certification portion under Part I,
you need to enter your religious group (on the first line) followed by the
religious district or congregation (on the second line). For example, if you
enter “Old Order Amish” as your religious group, then you would enter
“Conewango Valley North District,” “Conewango Valley West District,” etc.,
on the second line as the district. However, if you are Anabaptist or
Mennonite, enter the name of your religious group as “Unaffiliated Mennonite
Churches” or “Eastern Pennsylvania Mennonite Church,” etc., and the
congregation as “Antrim Mennonite Church (Anabaptist)” or “Bethel
Mennonite Church (Mennonite),” on the second line.
When to file. File Form 4029 when you want to apply for exemption from
social security and Medicare taxes. This is a one-time election. Keep your
approved copy of Form 4029 for your permanent records.
Where to file. Send the original and two copies of Form 4029 to:
Social Security Administration
Security Records Branch,
Attn: Religious Exemption Unit
P.O. Box 7
Boyers, PA 16020
If you are no longer a member or no longer follow the teachings of the
religious group, your exemption is no longer effective. Notify the Internal
Revenue Service by sending a letter to:
Department of the Treasury
Internal Revenue Service Center
Philadelphia, PA 19255-0733
Social security number. Enter your social security number on line 2. If you
do not have a social security number, file Form SS-5, Application for a Social
Security Card, at your local social security office. You can order Form SS-5
by calling 1-800-772-1213 or by visiting the website for Social Security at
www.socialsecurity.gov .
Effective period of exemption. An approved exemption granted to
employers and employees is effective on the first day of the first quarter after
the quarter in which Form 4029 is filed. An approved exemption granted to
self-employed individuals is effective when granted and applies for all years
for which you satisfy the requirements. The exemption will continue as long
as you, or in the case of wage payments, both the employee and employer
continue to meet the exemption requirements.
Signature. The completed Form 4029 must be signed and dated by the
applicant in Part I and by the authorized representative of the religious group/
district/congregation in Part II.

How to show exemption from self-employment taxes on Form 1040. If
the IRS returned your copy of Form 4029 marked “Approved,” write “Form
4029” on the “Self-employment tax” line in the Other Taxes section of Form
1040, page 2.

Instructions to Employers
Employees without Form 4029 approval. If you have employees who do
not have an approved Form 4029, you must withhold the employee’s share
of social security and Medicare taxes and pay the employer’s share.
Reporting exempt wages. If you are a qualifying employer with one or more
qualifying employees, you are not required to report wages that are exempt
under section 3127. Do not include these wages for social security and
Medicare tax purposes on Form 941, Employer’s QUARTERLY Federal Tax
Return, Form 943, Employer’s Annual Tax Return for Agricultural Employees,
or on Form 944, Employer’s ANNUAL Federal Tax Return. If you have
received an approved Form 4029, check the box on line 4 of Form 941 (line
3 of Form 944) and write “Form 4029” in the empty space below the check
box. If you file Form 943 and have received an approved Form 4029, write
“Form 4029” to the left of the wage entry spaces for Total wages subject to
social security taxes and Total wages subject to Medicare taxes.
Preparation of Form W-2. When you prepare Form W-2 for a qualifying
employee, enter “Form 4029” in the box marked “Other.” Do not make any
entries in the boxes for Social security wages, Medicare wages and tips,
Social security tax withheld, or Medicare tax withheld for these employees.
Privacy Act and Paperwork Reduction Act Notice. We ask for the
information on this form to carry out the Internal Revenue laws of the United
States. We need this information to ensure that you are complying with these
laws and to allow us to figure and to collect the right amount of tax. Applying
for an exemption from social security and Medicare taxes is voluntary.
Providing the requested information, however, is mandatory if you apply for
the exemption. Our legal right to ask for the information requested on this
form is Internal Revenue Code sections 6001, 6011, 6012(a) and 6109. Code
section 6109 requires that you provide your social security number on what
you file. If you fail to provide all or part of the information requested on Form
4029, your application may be denied. If you provide false or fraudulent
information, you may be subject to penalties.
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, U.S. commonwealths or
possessions for use in administering their tax laws. We may also disclose
this information to other countries under a tax treaty, to federal and state
agencies to enforce federal nontax criminal laws, or to federal law
enforcement and intelligence agencies to combat terrorism.
Please keep this notice with your records. It may help you if we ask 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 time needed to complete and file this form will vary depending on
individual circumstances. The estimated average time is: Recordkeeping, 6
min.; Learning about the law or the form, 19 min.; Preparing the form, 18
min.; Copying, assembling, and sending the form to the SSA, 16 min.
If you have comments concerning the accuracy of these time estimates or
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 Ave.
NW, IR-6526, Washington, DC 20224. Do not send the form to this address.
Instead, see Where to file on this page.