Form 15100 - Adoption Taxpayer Identification Number (Atin) Extension Request

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Department of the Treasury - Internal Revenue Service
15100
Form
Adoption Taxpayer Identification Number (ATIN)
(October 2017)
Extension Request
Complete this form, and fax or mail it to us at:
Standard:
Overnight:
Internal Revenue Service
Internal Revenue Service
Stop 6182
3651 S. Interregional Hwy 35
Austin, TX 73301-0066
Stop 6182
Austin, TX 78741
Fax number: (855) 250-1731
If you have any questions contact us at (737) 800-5511 (not toll free)
Contact Information
Name
Taxpayer Identification Number
Name
Taxpayer Identification Number
If you changed your address, write your new address below.
Address
City
State
ZIP code
Primary telephone number
Best time to call
Secondary telephone number Best time to call
a.m.
a.m.
p.m.
p.m.
Indicate which of the following circumstances apply to you
I received a social security number for
(Name of adoptee)
Write the social security number assigned
I need a 1 year extension for
ATIN
(Name of adoptee)
(ATIN assigned)
Reason
I couldn’t get a social security number for
ATIN
(Name of adoptee)
(ATIN assigned)
Reason
Status of your adoption
My adoption is final
My adoption is pending
I am enclosing documents the placement agency or agent signed
Original signatures of adoptive parents
Name
Signature
Date
(print/type)
Name
Signature
Date
(print/type)
15100
Catalog Number 69794D
Form
(Rev. 10-2017)

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