PTIN Supplemental Application For Foreign Persons
OMB No. 1545-2189
Without a Social Security Number
(Rev. December 2011)
Department of the Treasury
Internal Revenue Service
Do not submit this form if you have, or are eligible to get, a U.S. Social Security Number (SSN).
1 First name
2 Street address, apartment number, or rural route number. If you have a P.O. box, see instructions.
City or town, state or province, and country. Include ZIP code or postal code where appropriate.
3 Street address, apartment number, or rural route number. Do not use a P.O. box number.
City or town, state or province, and country. Include postal code when appropriate.
4 Date of birth (mm/dd/yyyy)
Country of birth
Name at birth (if different from above)
6 Foreign status and identification document(s) submitted (see instructions)
Foreign Driver's License
National ID Card
U.S. Military ID Card
Civil Birth Certificate
Foreign Military ID Card
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
Signature of applicant
For IRS Use Only
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 37764H