Form W-12 - Irs Paid Preparer Tax Identification Number (Ptin) Application And Renewal Page 3
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Form W-12 (Rev. 9-2012)
Page
13 Business
Domestic business phone number (optional)
International business phone number (optional)
Phone
Number
(
)
-
Ext.
+
14 Business Name
Enter the business name and website address (optional).
and Website
Address
If this is your initial application for a PTIN, continue to line 15. If you are renewing your PTIN, go to line 17.
Enter the address that you used on the last individual income tax return you filed.
15 Address of
Your
Last Individual
Income Tax
If you have never filed a federal income tax return, check here
. See line 15 instructions for documents that
Return Filed
must be submitted with this form. Skip line 16, and continue to line 17.
16 Filing Status
Single
Head of Household
and Tax Year
on Last
Married filing jointly
Qualifying widow(er) with dependent child
Individual
Income Tax
Married filing separately
Tax Year
Return Filed
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.
$64.25
$63.00
PTIN application
PTIN renewal
▶
▶
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
Under penalties of perjury, I declare that I have examined this application and to the best of my knowledge and belief, it
Sign
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
Date (MM,DD,YYYY)
Here
/
/
W-12
Form
(Rev. 9-2012)
For Internal Use Only
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