W-7A Application for Taxpayer Identification Number for Pendi

W-7A

Application for Taxpayer Identification Number
for Pending U.S. Adoptions

Form
(Rev. October 2017)

Department of the Treasury
Internal Revenue Service

▶

OMB No. 1545-0074

Go to www.irs.gov/FormW7A for instructions and the latest information.

Note: Don't file this form if you are eligible to obtain a U.S. social security number (SSN) for your adoptive child.

1

Adoptive
parent(s)
information

1a Parent’s last name

First name

Social security number

1b Parent’s last name

First name

Social security number

(see instructions)

2

Adoptive
parent(s)
address

Street address, apartment number, or rural route number. If you have a P.O. box, see the instructions.
City or town, state, and ZIP code

(see instructions)

3
4
5

Child’s name:

3a Last name

As it will appear
▶
on your tax return
3b Last name
Birth name if different
▶
and known . .
Date of birth (month, day, year)
Child’s birth

information
Placement
agency
information

Sign
Here

Middle name

First name

Middle name

Place of birth (city or town, and state) (If foreign address, see instructions)

Male
Name

Address

Date child
was placed
with adoptive
parents

Note: Be sure to attach the required documentation to Form W-7A. See instructions.
Under penalties of perjury, I declare that I have examined this application, including accompanying documentation and statements, and to
the best of my knowledge and belief, it is true, correct, and complete.
Signature of parent

Date (month, day, year)

Daytime phone number

Signature of parent

Date (month, day, year)

Daytime phone number

▲

Keep a copy of this
form for your
records.

Female

First name

▲
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 24309E

Form W-7A (Rev. 10-2017)