8946
PTIN Supplemental Application For Foreign Persons
Form
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).
Name
1 First name
Middle name
Last name
(see instructions)
Applicant's
2 Street address, apartment number, or rural route number. If you have a P.O. box, see instructions.
Complete
Mailing
City or town, state or province, and country. Include ZIP code or postal code where appropriate.
Address
Applicant's
3 Street address, apartment number, or rural route number. Do not use a P.O. box number.
Complete
Permanent
Non-U.S.
City or town, state or province, and country. Include postal code when appropriate.
Address
(see instructions)
4 Date of birth (mm/dd/yyyy)
Birth
5
Country of birth
Male
Information
Female
Name at birth (if different from above)
First name
Middle name
Last name
Foreign Status
6 Foreign status and identification document(s) submitted (see instructions)
Passport
Foreign Driver's License
National ID Card
and
Identification
Foreign Voter's
Information
U.S. Military ID Card
U.S. Visa
Registration Card
Civil Birth Certificate
Foreign Military ID Card
Other
Sign
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
Here
complete.
Phone number
Signature of applicant
Date
For IRS Use Only
8946
For Paperwork Reduction Act Notice, see instructions.
Form
(Rev. 12-2011)
Cat. No. 37764H