Form W-12 - Irs Paid Preparer Tax Identification Number (Ptin) Application And Renewal Page 3
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Form W-12 (Rev. 10-2017)
Page
11 Professional
Check all that apply. Note: DO NOT check any professional credentials that are currently expired or
Credentials
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.
Attorney—Licensed in which
jurisdiction(s):
Number(s):
Expiration Date(s):
Certified Public Accountant (CPA)—
Licensed in which jurisdiction(s):
Number(s):
Expiration Date(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)
State Regulated Tax Return Preparer
—Licensed in which jurisdiction(s):
Number(s):
Expiration Date(s):
Number:
Certifying Acceptance Agent (CAA)
None
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
Sign
the denial or termination of a PTIN.
Your signature (Please use blue or black ink)
Date (MM/DD/YYYY)
Here
/
/
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
W-12
Form
(Rev. 10-2017)
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