Fillable IRS Paid Preparer Tax Identification Number (PTIN) Application and Renewal 2017 Form-W-12

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IRS Paid Preparer Tax Identification Number (PTIN) Application and Renewal 2017 Form-W-12

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The IRS Paid Preparer Tax Identification Number (PTIN) Application and Renewal 2017 Form-W-12 form is 3 pages long and contains:

  • 1 signature
  • 29 check-boxes
  • 67 other fields

Country of origin: US
File type: PDF

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The Internal Revenue Service (IRS) is a government agency responsible for collecting taxes and administering the federal statutory tax laws of the United States. The IRS provide tax assistance to taxpayers and pursue and resolve fraudulent tax filings.

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Form W-12
(Rev. October 2017)
Department of the Treasury
Internal Revenue Service
IRS Paid Preparer Tax Identification Number (PTIN)
Application and Renewal
▶
Go to www.irs.gov/FormW12 for instructions and the latest information.
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 Year of
Application/
Renewal
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.
Current calendar year Next calendar year
Prior year(s) (YYYY): Check box(es) below for the prior year(s) you are renewing your PTIN. See line 2
instructions for additional guidance.
2015 2016 2017
Other prior year(s)
3 SSN and Date
of Birth
SSN
- -
Date of birth (MM/DD/YYYY)
/ /
4 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 or province, country, and ZIP or foreign postal code. Do not abbreviate name of country.
Phone Number ( ) -
5a Business
Mailing
Address and
Phone Number
Business address Check here if your business address is the same as your personal mailing address. If
different, enter it below.
City or town, state or province, country, and ZIP or foreign postal code. Do not abbreviate name of country.
Domestic business phone number
( )
- EXT.
International business phone number
+
b Business
Identification
Are you self-employed or an owner, partner, or officer of a tax return preparation business? Yes No
If “Yes,” then complete this line. If “No,” go to line 6.
Enter the business name.
Your CAF Number
EIN
-
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. 10-2017)
For Internal Use Only
F:
E:
A:
Form W-12 (Rev. 10-2017)
Page 2
7 Past Felony
Convictions
You must check
a box. If “Yes,”
you must
provide an
explanation.
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 8. If you are renewing your PTIN, go to line 10.
8 Address of
Your
Last U.S.
Individual
Income Tax
Return Filed
Enter the address used on your last U.S. individual income tax return you filed.
Check here if you have never filed a U.S. income tax return or do not have a U.S. income tax filing
requirement. See line 8 instructions for documents that must be submitted with this form and continue to
line 10.
9 Filing Status
and Tax Year
on Last U.S.
Individual
Income Tax
Return Filed
Single
Married filing jointly
Married filing separately
Head of Household
Qualifying widow(er) with dependent child
Tax Year (YYYY)
Note: If your last return was filed more than 4 years ago, see instructions.
10 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.
Form W-12 (Rev. 10-2017)
Form W-12 (Rev. 10-2017)
Page 3
11 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
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.
▲
Your signature (Please use blue or black ink) 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 PTIN applications. For additional information, refer to the separate Instructions for
Form W-12.
For Internal Use Only Form W-12 (Rev. 10-2017)
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IRS Paid Preparer Tax Identification Number (PTIN) Application and Renewal 2017 Form-W-12

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Completed 18 May 2019

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