Form 4361 - Application For Exemption From Self-Employment Tax For Use By Ministers, Members Of Religious Orders And Christian Science Practitioners
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1
2Application for Exemption From Self-Employment Tax
4361
OMB No. 1545-0074
Form
for Use by Ministers, Members of Religious Orders
(Rev. November 2005)
File Original
and Christian Science Practitioners
Department of the Treasury
and Two Copies
Internal Revenue Service
File original and two copies and attach supporting documents. This exemption is granted only if the IRS returns a copy to you marked “approved.”
1
Name of taxpayer applying for exemption (as shown on Form 1040)
Social security number
Number and street (including apt. no.)
Telephone number (optional)
(
)
City or town, state, and ZIP code
3
Date ordained, licensed, etc.
2
Check one box:
Christian Science practitioner
Ordained minister, priest, rabbi
(Attach supporting
Member of religious order not under a vow of poverty
Commissioned or licensed minister (see line 6)
document. See instructions.)
4
Legal name of ordaining, licensing, or commissioning body or religious order
/
/
Employer identification number
Number, street, and room or suite no.
City or town, state, and ZIP code
5
Enter the first 2 years, after the date shown on line 3, that you had net self-employment earnings of $400 or
more, any of which came from services as a minister, priest, rabbi, etc.; member of a religious order; or Christian
Science practitioner
6
If you apply for the exemption as a licensed or commissioned minister, and your denomination also ordains ministers, please indicate how your
ecclesiastical powers differ from those of an ordained minister of your denomination. Attach a copy of your denomination’s bylaws relating to
the powers of ordained, commissioned, and licensed ministers.
7
I certify that I am conscientiously opposed to, or because of my religious principles I am opposed to, the acceptance (for services I perform
as a minister, member of a religious order not under a vow of poverty, or a Christian Science practitioner) of any public insurance that
makes payments in the event of death, disability, old age, or retirement; or that makes payments toward the cost of, or provides services
for, medical care. (Public insurance includes insurance systems established by the Social Security Act.)
I certify that as a duly ordained, commissioned, or licensed minister of a church or a member of a religious order not under a vow of poverty,
I have informed the ordaining, commissioning, or licensing body of my church or order that I am conscientiously opposed to, or because of
religious principles, I am opposed to the acceptance (for services I perform as a minister or as a member of a religious order) of any public
insurance that makes payments in the event of death, disability, old age, or retirement; or that makes payments toward the cost of, or
provides services for, medical care, including the benefits of any insurance system established by the Social Security Act.
I certify that I have never filed Form 2031 to revoke a previous exemption from social security coverage on earnings as a minister, member
of a religious order not under a vow of poverty, or a Christian Science practitioner.
I request to be exempted from paying self-employment tax on my earnings from services as a minister, member of a religious order not
under a vow of poverty, or a Christian Science practitioner, under section 1402(e) of the Internal Revenue Code. I understand that the
exemption, if granted, will apply only to these earnings. Under penalties of perjury, I declare that I have examined this application and to
the best of my knowledge and belief, it is true and correct.
Signature
Date
Caution: Form 4361 is not proof of the right to an exemption from Federal income tax withholding or social security tax, the right to a parsonage
allowance exclusion (section 107 of the Internal Revenue Code), assignment by your religious superiors to a particular job, or the exemption or
church status of the ordaining, licensing, or commissioning body, or religious order.
For Internal Revenue Service Use
Approved for exemption from self-employment tax on ministerial earnings
Disapproved for exemption from self-employment tax on ministerial earnings
By
(Director’s signature)
(Date)
● A commissioned or licensed minister of a
General Instructions
cost of, or provides services for, medical
church or church denomination that ordains
care, including any insurance benefits
Section references are to the Internal
ministers, if you have authority to perform
established by the Social Security Act.
Revenue Code.
substantially all religious duties of your church
If you are a duly ordained, commissioned,
or denomination.
Purpose of form. File Form 4361 to apply for
or licensed minister of a church or a member
an exemption from self-employment tax if you
This application must be based on your
of a religious order not under a vow of
are:
religious or conscientious opposition to the
poverty, prior to filing this form you must
acceptance (for services performed as a
inform the ordaining, commissioning, or
● An ordained, commissioned, or licensed
minister, member of a religious order not
licensing body of your church or order that
minister of a church;
under a vow of poverty, or Christian Science
you are opposed to the acceptance of public
● A member of a religious order who has not
practitioner) of any public insurance that
insurance benefits based on ministerial
taken a vow of poverty;
makes payments for death, disability, old age,
service on religious or conscientious grounds.
● A Christian Science practitioner; or
or retirement; or that makes payments for the
4361
For Privacy Act and Paperwork Reduction Act Notice, see page 2
Cat. No. 41586H
Form
(Rev. 11-2005)
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