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. June 2017)
Department of the Treasury
Internal Revenue Service

▶ Go

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

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

Middle name

Initial application
2 Year of
Application/
Renewal

OMB No. 1545-2190

Last name

Renewal application

(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.
Next calendar year

Current calendar year

If you checked the “Renewal application” box and also need to renew for a previous calendar year(s), indicate
the year(s) below and see the line 2 instructions for additional guidance.
Prior year(s) (YYYY):
,
,
3 SSN and Date
of Birth

SSN

Date of birth (MM/DD/YYYY)
-

-

/

/

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 (

)

-

Business address (if different than line 4 information above)
5a Business
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. 6-2017)

Page 2

Form W-12 (Rev. 6-2017)

7 Past Felony
Convictions

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

Yes

No

If “Yes,” list the date and the type of felony conviction(s).

If this is your initial application for a PTIN, continue to line 8a. If you are renewing your PTIN, go to line 11.
8 Never Filed a U.S. Federal Income Tax Return
Address of
a If you have never filed a U.S. federal income tax return or do not have a U.S. federal income tax filing
Your
requirement, check here
. See line 8 instructions for documents that must be submitted with this form and
Last U.S.
continue to line 11.
Individual
b Enter the address used on your last U.S. individual income tax return you filed.
Income Tax
Return Filed
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.
Reserved
10 Reserved

Reserved

11 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.

www.irs.gov/w12

Form W-12 (Rev. 6-2017)

Page 3

Form W-12 (Rev. 6-2017)

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 Reserved

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

Reserved

Your signature

Date (MM/DD/YYYY)
/

/

How To File
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 paper Forms W-12. For additional information, refer to the separate Instructions for
Form W-12.

For Internal Use Only

www.irs.gov/w12

Form W-12 (Rev. 6-2017)