PTIN Supplemental Application For U.S. Citizens
Without a Social Security Number Due To
(Rev. October 2017)
OMB No. 1545-2188
Conscientious Religious Objection
Department of the Treasury
Go to for the latest information.
Internal Revenue Service
Do not submit this form if you have a U.S. Social Security Number (SSN).
To Be Completed by Preparer
2a Street address, apt. number, or rural route number. If you have a P.O. box, see instructions.
b City or town, state or province, country, and ZIP or foreign postal code
3a Date of birth (mm/dd/yyyy)
b Country of birth
c Name at birth (if different from line 1 above)
Citizenship and identification document(s) submitted (see instructions)
U.S. Driver’s License
U.S. State ID Card
Voter's Registration Card
U.S. Military ID Card
Foreign Military ID Card
Civil Birth Certificate
I certify that I am and continuously have been a member of
(Name of religious group)
(Religious district or congregation, and county and/or city, state, and ZIP code)
and as a follower of the established teachings of the group, I am conscientiously opposed to applying for and receiving a social
security number. Furthermore, I state that an application for a social security number was never filed by me or on my behalf, and that I
have never received a social security number. Under penalties of perjury, I declare that I have examined this application, including
accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete.
Signature of Applicant
To Be Completed by Authorized Representative of Religious Group
I certify that
is a member of
(Name of preparer)
(Name of religious group/district/congregation)
and as a dutiful follower of aforementioned religious group, has a religious objection to applying for and receiving a social security
Name of Authorized Representative (print or type)
Signature of Authorized
For Internal Use Only
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Cat. No. 37763W