Form W-7A
(Rev. October 2017)
Department of the Treasury
Internal Revenue Service
Application for Taxpayer Identification Number
for Pending U.S. Adoptions
Go to www.irs.gov/FormW7A for instructions and the latest information.
OMB No. 1545-0074
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
(see instructions)
1a Parent’s last name First name Social security number
1b Parent’s last name First name Social security number
2
Adoptive
parent(s)
address
(see instructions)
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
3
Child’s name:
As it will appear
on your tax return
Birth name if different
and known . .
3a Last name First name Middle name
3b Last name
First name Middle name
4
Child’s birth
information
Date of birth (month, day, year)
Female
Male
Place of birth (city or town, and state) (If foreign address, see instructions)
5
Placement
agency
information
Name Address
Date child
was placed
with adoptive
parents
Sign
Here
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
Keep a copy of this
form for your
records.
Date (month, day, year) Daytime phone number
Signature of parent
Date (month, day, year) Daytime phone number
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 24309E
Form
W-7A (Rev. 10-2017)
click to sign
signature
click to edit
click to sign
signature
click to edit
dd mmm yyyy
dd mmm yyyy
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome