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

W-12

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

Form
(Rev. October 2020)
Department of the Treasury
Internal Revenue Service

▶ Go

OMB No. 1545-2190

to www.irs.gov/FormW12 for instructions and the latest information.

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

Middle name

Last name

Initial application
Renewal application
2 Year of
Application/
Renewal

(Enter PTIN: P

)

If you checked the “Initial application” box and are submitting this form between October 1 and December 31,
indicate below whether you want your PTIN to be valid for the current calendar year or the next calendar year.
Current calendar year

Next calendar year

Prior year(s) (YYYY): Check box(es) below for the prior year(s) you are renewing your PTIN. See line 2
instructions for additional guidance.

3 SSN and Date
of Birth

2018
2019
2020
Other prior year(s)
If you are renewing and originally obtained a PTIN SSN
Date of birth (MM/DD/YYYY)
without a SSN, have you subsequently received a
/
/
SSN? If no, check box.
If yes, enter SSN
Street address. Use a P.O. box number only if the post office does not deliver mail to your street address.

4 Personal
Mailing
Address and
Phone Number City or town, state or province, country, and ZIP or foreign postal code. Do not abbreviate name of country.

Phone Number (

)

-

5a Business
Business address
Check here if your business address is the same as your personal mailing address. If
different, enter it below.
Mailing
Address and
Phone Number
City or town, state or province, country, and ZIP or foreign postal code. Do not abbreviate name of country.

Domestic business phone number
(
b Business
Identification

)

-

International business phone number
EXT.

+

Are you self-employed or an owner, partner, or officer of a tax return preparation business?
If “Yes,” then complete this line. If “No,” go to line 6.
Enter the business name.

Your CAF Number

EIN

Yes

No

EFIN
-

Website address (optional)

6 Email Address

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

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

Cat. No. 55469F

Form W-12 (Rev. 10-2020)
For Internal Use Only
F:
E:
A:

Page 2

Form W-12 (Rev. 10-2020)

Have you been convicted of a felony in the past 10 years?
7 Past Felony
Convictions
You must check
a box. If “Yes,” If “Yes,” list the date and the type of felony conviction(s).
you must
provide an
explanation.

Yes
No

If this is your initial application for a PTIN, continue to line 8. If you are renewing your PTIN, go to line 10.
Enter the address used on your last U.S. individual income tax return you filed.
8 Address of
Your
Last U.S.
Individual
Income Tax
Check here if you have never filed a U.S. income tax return or do not have a U.S. income tax filing
Return Filed
requirement. See line 8 instructions for documents that must be submitted with this form and continue to
line 10.
9 Filing Status
and Tax Year
on Last U.S.
Individual
Income Tax
Return Filed

Single

Head of Household

Married filing jointly

Qualifying widow(er) with dependent child

Married filing separately

Tax Year (YYYY)

Note: If your last return was filed more than 4 years ago, see instructions.
10 Federal Tax
Compliance

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

11 Data Security
I am aware that paid tax return preparers must have a data security plan to provide data and system security
Responsibilities protections for all taxpayer information.
Form W-12 (Rev. 10-2020)

Page 3

Form W-12 (Rev. 10-2020)

12 Professional
Credentials

Check all that apply. Note: DO NOT check any professional credentials that are currently expired or
retired. Enter state abbreviation and appropriate number(s). If the expiration date is left blank or incomplete,
then NO professional credential will be added when the application is processed.
Attorney—Licensed in which
jurisdiction(s):

Number(s):

Expiration Date(s):

Certified Public Accountant (CPA)—
Licensed in which jurisdiction(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 Return Preparer
—Licensed in which jurisdiction(s):

Number(s):

Expiration Date(s):

Certifying Acceptance Agent (CAA)

Number:

None

13 Fees

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

If you are applying for a PTIN or renewing your PTIN, your fee is $35.95. The fee is an application processing
fee and is nonrefundable. Full payment must be included with your application or it will be rejected. If your
application is incomplete and you do not supply the required information upon request, the IRS will be unable
to process your application. Make your check or money order payable to IRS Tax Pro PTIN Fee. Do not
paper clip, staple, or otherwise attach the payment to Form W-12.

Your signature (Please use blue or black ink)

How To File

Date (MM/DD/YYYY)
/

/

Online. Go to the webpage www.irs.gov/ptin for information. Follow the instructions to submit Form W-12. If you submit your
application online, your PTIN generally will be provided to you immediately after you complete the application.
By mail. Complete Form W-12. Send the form to:
IRS Tax Professional PTIN
Processing Center
1605 George Dieter PMB 678
El Paso, TX 79936
Note: Allow 4 to 6 weeks for processing of PTIN applications. For additional information, refer to the separate Instructions for
Form W-12.

For Internal Use Only

Form W-12 (Rev. 10-2020)