Form SSA-1458 Certification by Religious Group

See Revised Privacy
Act Statement Attached

SOCIAL SECURITY ADMINISTRATION

CERTIFICATION BY RELIGIOUS GROUP
(Regarding tenets or teachings on acceptance of Insurance
benefits and provision for dependent members)
Full Name and Mailing Address of Religious Group

Form Approved
OMB No. 0960-0093

PRIVACY ACT/PAPERWORK ACT NOTICE: The authority for
collecting the information requested on this form is
contained in Section 211 (c) (6) of the Social Security
Act. Submission of the information requested is voluntary.
The purpose for which the information is requested is to
determine if a religious group of which an individual is a
member qualifies for self-employment tax exemption.
Information you furnish on this form may be disclosed by
the Social Security Administration to another person or
governmental agency only with respect to Social Security
programs and to comply with Federal laws requiring the
exchange of information between the Social Security
Administration and another agency.

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

I am the
(Title)

and a duly appointed and authorized spokesman for the religious

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, disability, old-age, or retirement or makes
payments toward the cost of, or provides services for, medical care, including
the benefits of any insurance system established by the Social Security Act?

Yes

No

Yes

No

Yes

No

If "Yes," submit documents, statements, or other writings to support your
answer.
2. Is it the practice of this religious group to make provision for their dependent
members?
If "Yes," briefly describe how dependent members are provided for and submit
documents, statements, or other writings to support your answer.

3.

(a) Has this religious group been in existence at all times since
December 31, 1950?

DATE ESTABLISHED (if unknown. so
indicate)

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

Submit any available documents, writings, or other evidence to support your answers to (a) and (b) above.
Form SSA-1458 (11-1991) EF (9-2000)
Destroy Old Stock

(over)

Answer 4 only if this religious group was established after December 31, 1950.
4. (a) Is this religious group a division or offshoot of another
religious group with similar tenets and teachings?

Yes

No

If "yes," answer (b), (c), and (d) below. If "No," go on to item 5.
(b) Enter the full name of the group of which this group is a division or offshoot.

DATE ESTABLISHED (if unknown. so indicate)

(c) Enter the date the religious group in (b) above was established
(d) Are the tenets, teachings and practices of the religious group in
(b) above identical to those described in items 1 and 2 above?

Yes

No

If "No," explain the differences.

5. Have the tenets, teachings and practices of this religious group (and,
if applicable, the group of which it is a division or offshoot) been the
same as shown in items 1, 2, and 4 above at all times since December
31, 1950, or if later, the date the religious group was established?

Yes

No

If "No," explain any changes and indicate when changes took place.

6. I understand that it is the obligation of the group spokesman to notify the Social Security Administration in the
event there is any change in the tenets, teachings and practices of this religious group as indicated above.

PAPERWORK REDUCTION ACT STATEMENT: The Paperwork Reduction Act of 1995 requires us to notify
you that this information collection is in accordance with the clearance requirements of section 3507 of the
Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to, a
collection of information unless it displays a valid OMB control number. We estimate that it will take you
about 15 minutes to complete this form. This includes the time it will take to read the instructions, gather
the necessary facts and fill out the form. See Revised PRA

Statement Attached
SIGNATURE

TITLE

DATE