Form SSA-1458 Certification by Religious Group

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Fol'!'n Approved

OMi No. 08&0-0093

SOCIAL seCURITY AOMINISTRATION

PRIVACY ACTIPAPERWORK ACT NOTiCe: The authority
for collet;ting the information requested on this' form is
contained in Seotion 211 Ie} (6) of the Social Security
Ac'C. Submission of the intormalion requested is voluntary.
The purpose for which the information is requested is {o
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _-idetermine if a religious group of which an individual is iii
member quslifies for self-employment tax exemption.
Full Name and Mailing Address of Religious Group

CERTIFICATION BY RELIGIOUS GROUP
(Rflg(lrding tenets or t.achings 0" IIccept.nce of Insu,.nce
benefits lind provi"on for dep.endent membenl)

Information you furnish on this form may be diselo£ed by
the Social Security Administration to another person or
governmental agency only with respect to So~ial Security
programs and to comply wi'Ch Federal laws requiring 'Che
exchange of information between the Social Security
Administration and another .,geney.

See Revised Privacy Act
Statement

Print Your Name (First name, middle initial, last name)

and a duly appointed and authorized spokesman for

I am tne

ti,,, religious

ITitle)

group named above and certify the following information regarding this religious group;

1 , Do the established tenets or teachings of this religious: group oppose the
acceptance of benefits of any private or public insurance which makes
payments in the event of death, disabilitv, old-age, or '''tirement or makes
payments toward the cost of. or provides $ervices for. medical care. including
the benefits of any insurance system establisned by the Social Security Act?

DNO

DYes
If NYas, • submit documents, stBlements, or orher writings to support your

answer.

2. Is it the practice of this religious group to make provision for their dependent

DYe$

members?

DNa

If "Yes," briefly describe how dapendent members lire provided for and submit
documents, statementS, or other writings to support your tJlnswer.

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J. (a) Has this religious group been in existence at all times since
December 31, 19507
DYes

•

(b) Enter the date this religious group was established.

DATE ESTA.8I.ISHED lif unl(n".....
indicalOll

Submit an'll available documents wrl'linalt or other evidence to SUDDort your answers to la) and Ibl above.
Form SSA-1468 (11-1991) EF (9-,:aOOO)
Desll'Oy Old Stock

(over)

DNa
110

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• had after oecember 31 195 0
Answer 4 on Iv if th'1$ religious grouD.. was estabhs
4. la) Is this religious group a division or offshoot of fmother
religious group with similar tenets and teachifl9s1

0

No

Yes

II "yes, " answer Ib), leI, and (d) below. If "No, " go on to irem 6.
(b) Enter the full name of the group of which this group is a division or offshoot.

DATe ESTABLISI-4EO (if ulIlFile Typeapplication/pdfFile Modified2009-06-17File Created2009-03-16