8945
PTIN Supplemental Application For U.S. Citizens
Form
Without a Social Security Number Due To
OMB No. 1545-2188
(Rev. October 2014)
Conscientious Religious Objection
Department of the Treasury
Information about Form 8945 and its instructions is at
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Internal Revenue Service
Do not submit this form if you have a U.S. Social Security Number (SSN).
Part I
To Be Completed by Preparer
1
First name
Middle name
Last name
Name
2
Street address, apt. number, or rural route number. If you have a P.O. box, see instructions.
Applicant’s
Personal
City or town, state, and ZIP code
Mailing Address
3
4
Birth
Date of birth (mm/dd/yyyy)
Country of birth
Male
Information
Female
Name at birth (if different from above)
First name
Middle name
Last name
5
Citizenship and identification document(s) submitted (see instructions)
Citizenship
Passport/Passport Card
U.S. Driver’s License
U.S. State ID Card
and
Voter's Registration Card
U.S. Military ID Card
Foreign Military ID Card
Identification
Information
Civil Birth Certificate
Naturalization Papers
I certify that I am and continuously have been a member of
(Name of religious group)
since
(Religious district or congregation, and county and/or city, state, and ZIP code)
(Month)
(Day)
(Year)
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
Date
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Part II
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
number.
Name of Authorized Representative (print or type)
Address
Signature of Authorized
Representative
Title
Date
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For IRS Use Only
8945
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Form
(Rev. 10-2014)
Cat. No. 37763W