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 for instructions and the latest information.
OMB No. 1545-2190
1 Name and PTIN
(Print in ink or
First name Middle name Last name
Initial application
Renewal application
(Enter PTIN: P )
2 Year of
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
- -
Date of birth (MM/DD/YYYY)
/ /
4 Personal
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
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
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
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
Form W-12 (Rev. 10-2017)
Page 2
7 Past Felony
You must check
a box. If “Yes,”
you must
provide an
Have you been convicted of a felony in the past 10 years?
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
Last U.S.
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.
Income Tax
Return Filed
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
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.
If “No,” provide an explanation.
Form W-12 (Rev. 10-2017)
Form W-12 (Rev. 10-2017)
Page 3
11 Professional
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.
AttorneyLicensed in which
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)
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 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)
click to sign
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