Form W-12
(Rev. January 2013)
Department of the Treasury
Internal Revenue Service
IRS Paid Preparer Tax Identification Number (PTIN)
Application and Renewal
▶
Information about Form W-12 and its separate instructions is available at www.irs.gov/w12.
OMB No. 1545-2190
1 Name and PTIN
(Print in ink or
Type)
First name Middle name Last name
Initial application Renewal application (Enter PTIN: P )
2 Personal
Mailing
Address and
Phone Number
Street address. Use a P.O. box number only if the post office does not deliver mail to your street address.
City or town, state/province, and, if outside U.S., country. Include ZIP or postal code where appropriate. Do
not abbreviate name of country.
Phone Number ( ) -
3 SSN and Date
of Birth
SSN
- -
Date of birth (month, day, year)
/ /
4 Email Address Enter the email address that should be used to contact you.
5 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) and explain why the Internal Revenue
Service should consider you suitable to practice.
6 Federal Tax
Compliance
Are you current on both your individual and business federal taxes, including any corporate
and employment tax obligations?
Yes No
If you have never filed a U.S. individual income tax return because you are not required to do
so, check the “Yes” box.
If “No,” provide an explanation.
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Cat. No. 55469F
Form W-12 (Rev. 1-2013)
Form W-12 (Rev. 1-2013)
Page 2
7 Professional
Credentials
Check all that apply. Enter state abbreviation and appropriate number(s):
Attorney - Licensed in which state(s):
Number(s): Expiration Date(s):
Certified Public Accountant (CPA) -
Licensed in which state(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 Preparer-State(s):
Number(s): Expiration Date(s):
Certified Acceptance Agent
None
Skip lines 8, 9, and 10 if you are an attorney, CPA, or EA.
8 Form 1040
Preparation
Do you prepare Form 1040 series tax returns (or accompanying schedules) for
compensation? (If you ONLY prepare Form 1040-PR or Form 1040-SS for residents of Puerto
Rico, check “No.”)
Yes No
9 Supervised
Preparer
Determination
Are you employed by an attorney or CPA firm, or other recognized firm at least 80 percent
owned by attorneys, CPAs, or Enrolled Agents?
Yes No
Are you supervised by an attorney, CPA, EA, ERPA, or Enrolled Actuary?
Yes No
Does an attorney, CPA, EA, ERPA, or Enrolled Actuary sign all of the tax returns that you
prepare?
Yes No
If you checked “Yes” to all of these questions, you are a supervised preparer and must enter
your supervisor's PTIN: P
10 Reserved Reserved
Reserved
11 Business
Identification
Numbers
Are you self-employed or an owner, partner, or officer of a tax preparation business? Yes No
If you check “Yes,” complete this line. If you check “No,” go to line 12.
Your CAF Number
EIN
-
EFIN
12 Business
Mailing
Address
Business address
Business city or town, state/province, and, if outside U.S., country. Include ZIP or postal code where
appropriate. Do not abbreviate name of country.
Form W-12 (Rev. 1-2013)
Form W-12 (Rev. 1-2013)
Page 3
13
Business
Phone
Number
Domestic business phone number (optional)
( ) -
Ext.
International business phone number (optional)
+
14 Business Name
and Website
Address
Enter the business name and website address (optional).
If this is your initial application for a PTIN, continue to line 15. If you are renewing your PTIN, go to line 17.
15
Address of
Your
Last Individual
Income Tax
Return Filed
Enter the address that you used on the last individual income tax return you filed.
If you have never filed a federal income tax return, check here . See line 15 instructions for documents that
must be submitted with this form. Skip line 16, and continue to line 17.
16 Filing Status
and Tax Year
on Last
Individual
Income Tax
Return Filed
Single
Married filing jointly
Married filing separately
Head of Household
Qualifying widow(er) with dependent child
Tax Year
If your last return was filed more than 4 years ago, see instructions.
17 Fee If you are applying for a PTIN, your fee is $64.25. If you are renewing your PTIN, your fee is $63.00. The fee is
nonrefundable. Full payment must be included with your request/renewal or it will be rejected. Make your
check or money order payable to IRS Tax Pro PTIN Fee. Do not use paper clips or staples.
PTIN application
▶
$64.25 PTIN renewal
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$63.00
If you are filing Form W-12 to apply for a PTIN, and you anticipate that you will not receive your PTIN until after
October 15th, check the box to indicate whether you want your PTIN to be valid for the current calendar year or
the next calendar year.
Current calendar year
Next calendar year
Sign
Here
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.
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Your signature Date (MM,DD,YYYY)
/ /
Form W-12 (Rev. 1-2013)
For Internal Use Only
