Form W-12 - Irs Paid Preparer Tax Identification Number (Ptin) Application And Renewal
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1
2
3W-12
IRS Paid Preparer Tax Identification Number (PTIN)
Form
Application and Renewal
OMB No. 1545-2190
(Rev. October 2017)
Department of the Treasury
Go to for instructions and the latest information.
▶
Internal Revenue Service
1 Name and PTIN
First name
Middle name
Last name
(Print in ink or
Type)
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,
Application/
indicate below whether you want your PTIN to be valid for the current calendar year or the next calendar year.
Renewal
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
SSN
Date of birth (MM/DD/YYYY)
of Birth
-
-
/
/
Street address. Use a P.O. box number only if the post office does not deliver mail to your street address.
4 Personal
Mailing
Address and
Phone Number
City or town, state or province, country, and ZIP or foreign postal code. Do not abbreviate name of country.
Phone Number (
)
-
5a Business
Business address
Check here if your business address is the same as your personal mailing address. If
Mailing
different, enter it below.
Address and
Phone Number
City or town, state or province, country, and ZIP or foreign postal code. Do not abbreviate name of country.
Domestic business phone number
International business phone number
(
)
-
EXT.
+
b Business
Are you self-employed or an owner, partner, or officer of a tax return preparation business?
Yes
No
Identification
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.
W-12
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Form
(Rev. 10-2017)
Cat. No. 55469F
For Internal Use Only
F:
E:
A:
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