Form W-12 - Irs Paid Preparer Tax Identification Number (Ptin) Application And Renewal Page 2

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Form W-12 (Rev. 10-2017)
Page
7 Past Felony
Yes
Have you been convicted of a felony in the past 10 years?
Convictions
No
You must check
If “Yes,” list the date and the type of felony conviction(s).
a box. If “Yes,”
you must
provide an
explanation.
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
Enter the address used on your last U.S. individual income tax return you filed.
Your
Last U.S.
Individual
Income Tax
Check here if you have never filed a U.S. income tax return or do not have a U.S. income tax filing
Return Filed
requirement. See line 8 instructions for documents that must be submitted with this form and continue to
line 10.
9 Filing Status
Single
Head of Household
and Tax Year
on Last U.S.
Married filing jointly
Qualifying widow(er) with dependent child
Individual
Income Tax
Married filing separately
Tax Year (YYYY)
Return Filed
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
Compliance
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.
W-12
Form
(Rev. 10-2017)

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