Form W-12 IRS Paid Preparer Tax Identification Number (PTIN) Appli

W-12

Form
(Rev. January 2013)
Department of the Treasury
Internal Revenue Service

IRS Paid Preparer Tax Identification Number (PTIN)
Application and Renewal
▶ Information

OMB No. 1545-2190

about Form W-12 and its separate instructions is available at www.irs.gov/w12.

1 Name and PTIN First name
(Print in ink or
Type)

Middle name

Last name

Initial application
Renewal application
(Enter PTIN: P
Street address. Use a P.O. box number only if the post office does not deliver mail to your street address.
2 Personal
Mailing
Address and
Phone Number 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
4 Email Address

5 Past Felony
Convictions

SSN

Phone Number (
Date of birth (month, day, year)

/
Enter the email address that should be used to contact you.

)

)

-

/

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

Yes

No

Yes

No

If “Yes,” list the date and the type of felony conviction(s) and explain why the Internal Revenue
Service should consider you suitable to practice.

6 Federal Tax
Compliance

Are you current on both your individual and business federal taxes, including any corporate
and employment tax obligations?
If you have never filed a U.S. individual income tax return because you are not required to do
so, check the “Yes” box.
If “No,” provide an explanation.

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

Cat. No. 55469F

Form W-12 (Rev. 1-2013)

Page 2

Form W-12 (Rev. 1-2013)

7 Professional
Credentials

Check all that apply. Enter state abbreviation and appropriate number(s):
Attorney - Licensed in which state(s):

Number(s):

Expiration Date(s):

Certified Public Accountant (CPA) Licensed in which state(s):

Number(s):

Expiration Date(s):

Enrolled Agent (EA)

Number(s):

Expiration Date(s):

Enrolled Actuary

Number(s):

Expiration Date(s):

Enrolled Retirement Plan Agent (ERPA)

Number(s):

Expiration Date(s):

State Regulated Tax Preparer-State(s):

Number(s):

Expiration Date(s):

Certified Acceptance Agent
None

Skip lines 8, 9, and 10 if you are an attorney, CPA, or EA.
8 Form 1040
Do you prepare Form 1040 series tax returns (or accompanying schedules) for
Preparation
compensation? (If you ONLY prepare Form 1040-PR or Form 1040-SS for residents of Puerto
Rico, check “No.”)
Are you employed by an attorney or CPA firm, or other recognized firm at least 80 percent
9 Supervised
owned by attorneys, CPAs, or Enrolled Agents?
Preparer
Determination Are you supervised by an attorney, CPA, EA, ERPA, or Enrolled Actuary?
Does an attorney, CPA, EA, ERPA, or Enrolled Actuary sign all of the tax returns that you
prepare?
If you checked “Yes” to all of these questions, you are a supervised preparer and must enter
your supervisor's PTIN: P
10 Reserved

Yes

No

Yes
Yes

No
No

Yes

No

Yes

No

Reserved

Reserved

11 Business
Identification
Numbers
12 Business
Mailing
Address

Are you self-employed or an owner, partner, or officer of a tax preparation business?
If you check “Yes,” complete this line. If you check “No,” go to line 12.
Your CAF Number
EIN
EFIN
Business address

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

Form W-12 (Rev. 1-2013)

Page 3

Form W-12 (Rev. 1-2013)

13 Business
Phone
Number

Domestic business phone number (optional)

International business phone number (optional)

(
)
Ext.
+
14 Business Name Enter the business name and website address (optional).
and Website
Address
If this is your initial application for a PTIN, continue to line 15. If you are renewing your PTIN, go to line 17.
15 Address of
Your
Last Individual
Income Tax
Return Filed
16 Filing Status
and Tax Year
on Last
Individual
Income Tax
Return Filed

Enter the address that you used on the last individual income tax return you filed.

If you have never filed a federal income tax return, check here
. See line 15 instructions for documents that
must be submitted with this form. Skip line 16, and continue to line 17.
Single
Head of Household
Married filing jointly
Married filing separately

Tax Year

If your last return was filed more than 4 years ago, see instructions.
If you are applying for a PTIN, your fee is $64.25. If you are renewing your PTIN, your fee is $63.00. The fee is
nonrefundable. Full payment must be included with your request/renewal 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.

17 Fee

PTIN application ▶

$64.25

PTIN renewal ▶

$63.00

If you are filing Form W-12 to apply for a PTIN, and you anticipate that you will not receive your PTIN until after
October 15th, check the box to indicate whether you want your PTIN to be valid for the current calendar year or
the next calendar year.
Current calendar year
Next calendar year
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. I understand any false or misleading information may result in criminal penalties and/or
the denial or termination of a PTIN.

▲

Sign
Here

Qualifying widow(er) with dependent child

Your signature

Date (MM,DD,YYYY)
/

/
Form W-12 (Rev. 1-2013)

For Internal Use Only